Today in a discussion about what makes an excellent clinician a colleague suggested that he didn’t like the concept of ‘excellent’ because it implied aiming to be perfect – which obviously (perhaps) one can’t achieve.

I reject this assertion.

We need some assumptions. Yes – we can’t be perfect – but we can excel.

The dictionary definition(s) of excellence is:

n
1. the state or quality of excelling or being exceptionally good; extreme merit; superiority
2. an action, characteristic, feature, etc., in which a person excels

I’d like to propose a different definition of excellence that ignores perfection. Being excellent means always trying to be better and to do better. I believe this is the intent of pursuing excellence in healthcare. And yes – for some of the consumers this will be a perfect outcome.

So the RACP (Royal Australasian College of Physicians) has self-management as part of its’ Professional Qualities Curriculum. Well this wasn’t taught at medical school and it isn’t being taught or assessed by the college. Nor is it getting assessed for CPD/CME points.

Self-management includes stress management. This includes addressing work-life-balance.

My first comment is that the notion of ‘addressing work-life-balance’ is more likely-than-not written buy a bunch of middle-aged to elderly white males who have little concept of what outsiders to consider to be work-life balance. This is a homily. If somebody is happy working – let them do it. It is their source of balance.

But seriously. I’ve never really had a proper discussion with one of my trainees about stress management. At least in a serious sense. We’ve discussed ‘debriefing’ with one’s partner or colleagues but stress management can go beyond this.

Several lines of research are suggesting but haven’t definitively proven the role of mindfulness for managing patient symptoms and stress. This work might also provide guidance for physicians for managing stress.

Currently I’m testing the Headspace app for iPhone. In the old parlance this is meditation but mindfulness is a more approachable term for us folk who aren’t into alternative medicine. Interestingly I think I couldn’t have done this 5 or 10 years ago but now it is sitting nicely.

I don’t know if mindfulness training is going to improve my overall well-being but it seems mostly harmless and it is teachable to junior doctors who are having to deal with different stressors to me. There are flow on effects – if your doctor is better rested then he/she might manage your case better. If your doctor understands mindfulness-based therapy then he/she might recommend this app.

This will be short and sweet.

One thing they didn’t teach in medical school was how to teach. Maybe we weren’t taught this because we might start charging for all of the unpaid teaching time that we provide.

Teaching is obviously important because we need to teach the up-&-coming doctors how to be, well, doctors, but also because by teaching we get to explore for ourselves our own level of expertise and understanding. Good teachers usually know their stuff backwards and can expalin it simply.

Teaching can be hard and like everything needs to be tailored to the audience, the occasion and the context. I’ve certainly made heaps of mistakes along the way….apparently I’m scary.

Dr Fiona Lake and her colleagues have recognized this and come up with Teaching on the Run. Look up the website or check out the articles in the Medical Journal of Australia.

One of the ways medicine plays games with itself is in the provision of names for modes and models of care. Names are used to brand modes of care and perhaps in an unnecessary manner.

Some examples that come to mind include the distinction between palliative care and supportive care. Respectively these terms have come to mean palliation at the end-of-life and palliation through the rest of an illness. At the end of the day the aim is to effectively manage physical, psychosocial and existential issues and symptoms related to an illness regardless of the phase of the illness. The different terms serve to support different political and economic agendas.

Another potential example is the concept of the medical home. The medical home is a model of care designed to provide high quality care through a primary care practice, arguably, as opposed to fragmented care in a specialist system. An alternate way of thinking of the medical home is that it is about having a family doctor. Yes, I’ll acknowledge that the concept is expanded to include team-based care coordination, etc, but the bottomline is that the concept is about good primary care.

Recently in the oncology world the concept of survivorship has become fashionable for research and service delivery. Interestingly a lot of the interventions that are being demonstrated to potentially be of benefit for cancer survivors overlap with those which are of interest to preventive medicine. These include managing diet and weight, activity levels and fitness, and mindfulness. In otherwords both survivorship and preventive medicine are about wellness.

Holistic medicine, the bio-psycho-social model of healthcare and the whole person movement are another example of word-games in medical care.

There are two themes that underpin these comparisons. The first is an emphasis on delivering quality care for the unwell regardless the context of the illness, both in terms of physical setting and the phase of the illness. The second is wellness or being healthy, underpinned by personal empowerment around healthcare decisions. If we can focus on these principles rather than specific silos of thinking that they might support then perhaps we can start to see the forest through the trees. Lets talk about quality of care and wellness.

Possibly more confronting that being called by a nurse to actually go and review the person who has just died and having to check for vital signs in front of a family is then needing to go and complete the certificate of death documentation. Nobody taught me this in medical school and like all good forms often the fields don’t make sense.

As this post, Quantified Death, in the Health Care Blog points out, because doctors aren’t trained to fill out death certificates a lot of the data about why people died is nonsense. ‘Brain failure’, ‘full body organ failure’, ‘old age’ really don’t count as a cause of death.

Doctors need to be taught how to complete death certificates but it is also not just a matter of completing the form correctly for the sake of data collection. Perhaps underpinning the problem is our own failure to really understand why and how people die. This needs to be discussed more at medical school. A case in point when I discuss Not for Resuscitation orders with patients and their families I no longer refer to attempting resuscitation when their heart and lungs stop working – I simply refer to the person dying.

In the last fortnight the new registrars started and they have been thrown into being ‘On Call’. This means fielding calls from doctors in the emergency department about patients who might need admission to hospital.

This is something I do all the time and it is interesting to reflect that nobody actually taught me what to do – one day I was on a roster. I guess the expectation was that I’d been on the other side of the phone making calls to consultants so of course I knew what to do. But actually taking the calls is different from making the calls. For starters you might be asleep when the call comes in.

@cancersolutions (Matthew Links) & I have been pondering the question of what needs to be taught in medical school about being on call.

Some of the key competencies for oncology on call that we’ve identified include:

1. Assessing the reliability of the information obtained over the phone and the competence of the person making the call.
2. Prioritizing problems and anticipating other problems that the caller may not have thought of
3. Determining the appropriate location of care for a patient – does the patient need to go to a high dependency unit or even transfer to a different institution?
4. Appropriately involving or referring to other medical teams
5. Addressing supportive care and symptom management needs
6. Actively considering end-of-life issues and advanced directives
7. Communicating with other teams
8. Using the call as a teachable moment
9. Using the call as an opportunity for reflection – what would I have done differently next time?
10. Managing the caller – sometimes one gets a long-winded story that totally misses the problem….it can help to recalibrate the call e.g by returning to ask what was the reason the patient came to the ED?

Being on call can be stressful especially if there are a lot of calls. Learning how to do it properly can certainly make life easier.

If you’re interested in the topic of being on call my next post will be on how remote presence technology could be a disruptive innovation for the on call doctor.