“Just a word”

In an official Medical Society Blog the following words were recently used in response to thoughts that I had submitted on a medical subject.  These singular words were put in inverted commas by a most senior healthcare professional who does not know me.

The Medical Society involved has since removed the post:

I share the view of Barrack Obama that we should all try and engage in debate with those who may have different views.

I would suggest that such “one word” approach [with words used to stain] may not encourage helpful debate.

Frailty – nothing about us without us

In September 2016, Professor Martin Vernon, National Clinical Director for Older People and Integrated Care at NHS England stated why diagnosing frailty is important:

In the same month Professor David Oliver had this Acute Perspective published in the British Medical Journal. It attracted over twenty responses many of which, but not all, were supportive.

I submitted this response as I was not convinced that “frailty” was inherently any less likely to stigmatise our older generation:

A year later, Dr Steve Parry, the Vice President of the British Geriatrics Society (BGS) had this perspective  published on the British Geriatrics Society Blog , asking “when does a well-meaning medical fashion become a potentially destructive fad?” This perspective also attracted over twenty responses.

A week later, the former President of the British Geriatrics Society, Professor David Oliver argued why he was “fine with Frailty”:

Dr Shibley Rahman, an Academic in Frailty and Dementia and has outlined why he is of the view that such a model, based on deficits only, if applied to our older generation could cause harm. This article also attracted many responses.

In a recent Acute Perspective Professor Oliver outlined his concern that the British public may not have realistic expectations when it comes to frailty and “progressive dwindling”:

My understanding is that the term “progressive dwindling” was first used by George J. Romanes in this 1893 book:

This is the context in which the term is used:

The dictionary definition of “inutility” is: uselessness or a useless thing or person.

Healthcare Improvement Scotland has been concentrating on frailty as one of its National Improvement initiatives. This first started in April 2012 and so has developed significantly in the five years that have followed. NHS Scotland staff have been reminded to “THINK FRAILTY”. Up until now the focus has been on deficits and how to “screen” for these with “toolkits”.

In a BBC Radio Scotland “Thought for the Day”, the broadcaster and writer Anna Magnusson recently considered the language that we use in relation to our older generation. I made this short film using her words and voice. I have shared it with Anna Magnusson and she wrote a kind personal response to me:

We are far more than our labels from omphalos

These words from an Edwin Morgan poem resonated with me as a description of the complexity of ageing:

The people best placed to assist in understanding the complexities of ageing and the language best used to describe it are surely the older generation themselves.

If NHS Scotland has been genetically-modified with QI

It is most welcome to hear from Philippa Whitford about positive outcomes of NHS Scotland’s collaborative approach to quality improvement and the learning that this might provide for the rest of the UK. I share Philippa Whitford’s concerns about the potential consequences of competitive systems such as occurs more in NHS England with providers, commissioners and contracts and the inevitable fragmentation that this brings. The integrated approach taken in Scotland along with the engagement of patients and frontline practitioners is indeed something to be most positive about.

However, NHS Scotland’s approach to Quality Improvement is based on what is known as “improvement science”. This is a relatively new approach to science introduced from the USA and based on methodologies from the engineering and airline industries. The Health Foundation, in its ‘Evidence Scan’ found a “real paucity of evidence about the field of improvement science” . The Health Foundation found papers on the conceptual nature of Improvement Science but concluded that: “none of these could be said to be seminal pieces of research acting as building blocks for the field as a whole”.

As far back as 2007 Brent et al identified that “ethical issues arise in QI because attempts to improve quality may inadvertently cause harm, waste scarce resources, or affect some patients unfairly.”

Scotland has two key National Improvement initiatives for older people in acute hospital care. One is for Delirium and the other is for Frailty.

The QI initiative on Delirium was reliant upon “screening tools” that were effectively made mandatory for all those aged 65 years and over admitted to hospital. Healthcare Improvement Scotland measured the “compliance” with the use of these “screening tools” across Scotland. On the wards I was finding that these tools were not infrequently being interpreted as diagnostic and that older people were sometimes considered as lacking in “capacity” on this basis. I was also concerned that this approach could lead to greater use of antipsychotic medication.

The QI initiative on Frailty is currently being implemented across NHS Scotland. This is despite the fact that there is no internationally accepted clinical definition for Frailty. More “screening tools” have been developed by Healthcare Improvement Scotland and “Frailty Hubs” are now being set up in most NHS Boards. It may be worth noting recent high-level disagreement amongst British Geriatricians about the validity of the “Frailty Industry” as one senior Geriatrician described it.

The experience of these national initiatives perhaps highlights the limitations of approaches which work best in mechanical settings. The same success cannot be guaranteed when applied to more complex presentations such as delirium and frailty.

It has recently been stated that “ethical approval is less burdensome” for QI. However I suggest that we must be wary of taking shortcuts that may result in potential harm as well as potential good. This is why ethics and philosophy have an established role in science.

Another risk is that if science is pre-determined as “improvement”, this may limit the acceptance of critical thinking.

Philippa Whitford concludes that in NHS Scotland “Quality improvement has made its way into the DNA of frontline staff”. I share the view that Quality Improvement has much to offer. However, if NHS Scotland has been genetically-modified with QI let us hope that the wider considerations necessary for science are included in the base-code.

Dr Peter J Gordon
Psychiatrist for Older Adults
NHS Scotland

 

‘Progress depends on the unreasonable man’

Professor David Oliver is a doctor that I have huge respect for. His views, as expressed in the BMJ, and thus in short form, generally accord with mine [this is an observation and not a statement about the merit of our opinions].

As an NHS doctor who has ‘spoken up’ I read this ‘BMJ Acute Perspective’ by Professor Oliver with both interest and with gratitude.

I worry (perhaps I am not alone in this worry) if I might be considered as either “reasonable” or “unreasonable”? However I have a greater need, and that is to be true to who I am.

Truth generally rests between words like “reasonable” and “unreasonable”. This is  territory that needs freedom.

 

Quality Improvement and ethics

Response by Dr Sian F Gordon and Dr Peter J Gordon, 4 June 2017

This Acute Perspective by Dr David Oliver has our interest, in part because we all embarked on our career in medicine around the same time.We very much share Dr Oliver’s advocacy for “the actions and engagement of frontline practitioners and the real world context in which they work” and agree that these “are critical to success.”

We would like to contribute in the spirit of critical thinking  regarding the place of ethics in Quality Improvement (QI).

Dr Oliver states that QI can deliver “tangible outcomes” and that it has “a methodological and theoretical rigour and peer community of its own”.

As far back as 2007 Brent et al identified that “ethical issues arise in QI because attempts to improve quality may inadvertently cause harm, waste scarce resources, or affect some patients unfairly.”

Dr Oliver states that “ethical approval is less burdensome” for QI. We are of the view that ethics must be one of the necessary starting principles for any QI work and would argue that any attempt, however well intentioned, to demote ethics from this role might result in outcomes that may not be described as “improvement”.

 

 

‘It was odd being dead’

This is a fictional film. It is about a teddy bear, Dr Hale Bopp and a day of two halves. In the morning Dr Hale Bopp goes exploring in the Scottish Borders and he comes across the ruin of the Monteath mausoleum on Gersit Law. The oak door of the mausoleum has been breached and one can get inside and be with Monteath and the two angels that guard this forgotten statesman. Above him the dome has beautiful window stars to the universe beyond.

Dr Hale Bopp is a well-travelled bear and is constantly exploring, enjoying and reflecting upon the world in which he lives. The guid doctor has come to the view that life is complex, diverse and sometimes “messy”. He leaves the Monteath mausoleum with paws that were muddy and heads for a different afternoon. An afternoon of Appraisal to ensure that as a fictional bear and doctor that he is providing Good Medical Practice.

So that was the day of two halves. This film is about that.

Dr Hale Bopp is getting on a bit now and is at the end of his fictional medical career. One day soon he will retire from being a doctor but meantime he is of the view that his wanderings, philosophical and creative between the arts and sciences, has been nothing but to the benefit of the patients that he cares for.

Important note:
None of the words used in this film are those of the filmmaker. They are “borrowed” from C.P. Snow’s “Corridors of Power”; Evelyn Waugh’s “Decline and Fall”; and Jessie Burton’s novel “The Muse”.

‘It was odd being dead’ from omphalos on Vimeo.

Source material:
(1) Physicians of the future: Renaissance of Polymaths? By B F Piko and W E Stempsey. Published in The Journal of the Royal Society for the Promotion of Health. December 2002, 122(4), pp. 233-237
(2) Time to rethink on appraisal and revalidation for older doctors. By Dr Jonathan D Sleath. Letter published in the BMJ, 30 December 2016, BMJ2016;355:i6749
(3) Career Focus: Appraising Appraisal. Published in the BMJ 21st November 1988, BMJ1988;317:S2-7170
(4) Revalidation: What you need to know. Summary advice for Regulators. General medical Council.
(5) The Good Medical Practice Framework for Appraisal and Revalidation. General medical Council.
(6) Taking Revalidation Forward: Sir Keith Pearson’s Review of Medical Revalidation. January 2017.
(7) GMC response to Sir Keith Pearson’s report on Taking Revalidation Forward.

Music credits (under common license, thank you Dexter Britain):

(1) Perfect I am not – by Dexter Britain
(2) Telling stories – by Dexter Britain


Validation of an OPAC delirium tool

In this post I wish to explore validation of one of the tools recommended by Healthcare Improvement Scotland to identify delirium in acute hospital.

The website for the 4AT can be accessed here. It states that:

4AT validated

Looking at these two published studies in turn:

053Tools

The following caveats are included in this validation study:

  1. One of the  main features of the 4AT test is that “no special training is required”. In this study 4AT assessments were “performed by experienced physicians, though no specific training in the 4AT was given”. The authors conclude that: “Further research is needed to assess the ease of use of 4AT among other professional groups of varying levels of seniority.”
  2. The authors also state that this study “did not assess inter-rater reliability for the 4AT or the reference standard assessment”
  3. This study was not set in A& E or hospital front-door settings.
  4. The authors of this study conclude that “because of insufficient power, we were not able to analyse the characteristics of misclassified (false negative and false positive) patients.”
  5. The authors of this study advise that “future studies in larger populations and other centres should further assess its performance, including the determination of whether detection of delirium using the 4AT may improve the clinical outcomes of patients.”

It seems very clear to me that the authors of this study have recognised that further assessment of the 4AT is required before its use can be considered to be reliable in populations other than that studied by the authors.

Here follows the second published study quoted as evidence of validation of the 4AT test:

054Tools

This study is set specifically in a Stroke Unit and thus its conclusions cannot be generalised to all acute admissions.

It is therefore welcome to see that a major study is being undertaken to further evaluate the 4AT test:

4AT validated UK Gov

Here are some extracts from the study protocol:

055Tools       051Tools

This study is not yet published. The protocol states that: 4AT further research

This research study has had ethical approval and is rigorous in its approach to patient consent. Obviously a research study includes different ethical dimensions when it comes to consent but, as I have reasoned in my last post, the use of a test that still remains to be fully evaluated also requires that ethical rigour.

informed consent

The study protocol outlines the hope that:

NICE delirium 2

However the study protocol also states that:

knowledge-mobilisation-4at-3

Healthcare Improvement Scotland, in their recent reports state that “OPAC tools work and are working in hospitals across Scotland”. One of these tools is the 4AT test.

In summary there must always come a stage where a research tool is evaluated in the ‘real world’. My concern is that Healthcare Improvement Scotland is encouraging the use of the 4AT in hospitals across Scotland without making it clear that it is still under evaluation. Given that “compliance” with the use of “OPAC tools” is being used as a measure of quality of care by Healthcare Improvement Scotland, it would seem justified to express concern about this.

Professor David Oliver recently had an opinion piece published 
in his regular BMJ column; Delirium Matters (24th May 2016). 
I wrote to Professor Oliver by e-mail to say that I agreed with most 
of what he said but that I was not as convinced as he was 
that the 4AT has been validated.

Professor David Oliver replied that it "beggared belief" 
that I would "nit pick" about this.

I replied:

"In terms of the word “validated”: this has a very clear 
scientific definition. My reading of the science so far is 
that the 4AT tool has not been validated either for 
screening or detection. 

My concern is a general one: that “simple”, “quick” and 
“no specialist training required” tools have the potential 
for harm when over-relied upon and that they may give 
the impression that a very complex condition/state 
is more simple and better understood than it really is."