Grant Phelps

Paracetamol overdose and hepatotoxicity at a regional australian hospital : a 4-year experience

Abstract

Clinical sensemaking: a systematic approach to reduce the impact of normalised deviance in the medical profession

organisational culture, quality assurance, health care, state medicine, Great Britain, Health care reform, quality improvement

Why has the safety and quality movement been slow to improve care

Buist and Middleton lament that the safety and quality ‘agenda’ has failed to fundamentally alter the safety of healthcare systems, in part because of the disengagement of doctors from their responsibilities for patient safety . While there have been discernable improvements in the efficiency and effectiveness of care in some settings, patients still experience unacceptable harm and often struggle to have their voices heard; processes are not as efficient as they could be; and costs continue to rise at alarming rates while quality issues remain . Perhaps of most concern, recent public reports into health system failures continue to document a widespread lack of attentiveness to patient concerns, a culture of denial and widespread lack of professionalism . Alarmingly, clinician discontentment, cynicism and burn‐out are reflected in antagonistic language by clinicians about the healthcare system and their patients. Taken together with the many dissatisfied and now more vocal patient groups, all point to an unprecedented crisis of faith in our healthcare systems which has been getting worse over past decade . This personal perspective aims to address the fundamental tensions that are keeping much of healthcare reform efforts from successfully transforming the culture and outcomes except at the margins.

Reasons and remedies for under-representation of women in medical leadership roles: a qualitative study from Australia

Objective To elicit medical leaders’ views on reasons and remedies for the under-representation of women in medical leadership roles. Design Qualitative study using semistructured interviews with medical practitioners who work in medical leadership roles. Interviews were transcribed verbatim and transcripts were analysed using thematic analysis. Setting Public hospitals, private healthcare providers, professional colleges and associations and government organisations in Australia. Participants 30 medical practitioners who hold formal medical leadership roles. Results Despite dramatic increases in the entry of women into medicine in Australia, there remains a gross under-representation of women in formal, high-level medical leadership positions. The male-dominated nature of medical leadership in Australia was widely recognised by interviewees. A small number of interviewees viewed gender disparities in leadership roles as a ‘natural’ result of womens childrearing responsibilities. However, most interviewees believed that preventable gender-related barriers were impeding womens ability to achieve and thrive in medical leadership roles. Interviewees identified a range of potential barriers across three broad domains—perceptions of capability, capacity and credibility. As a counter to these, interviewees pointed to a range of benefits of women adopting these roles, and proposed a range of interventions that would support more women entering formal medical leadership roles. Conclusions While women make up more than half of medical graduates in Australia today, significant barriers restrict their entry into formal medical leadership roles. These constraints have internalised, interpersonal and structural elements that can be addressed through a range of strategies for advancing the role of women in medical leadership. These findings have implications for individual medical practitioners and health services, as well as professional colleges and associations.

Audit of sedated versus unsedated gastroscopy: do patients notice a difference?

Abstract Unsedated diagnostic gastroscopy has become widely accepted as a diagnostic procedure which avoids the risk of an anaesthetic. It also provides advantages for patients and hospitals in converting the procedure to an ambulatory care investigation. Patient perception of the procedure can sometimes differ from that of medical and nursing staff. We have decided to report our usual clinical practice by auditing 100 consecutive patients undergoing this procedure in a large rural private hospital. Patient tolerance was analyzed in various categories including degree of comfort, degree of pain, ease of breathing and willingness to repeat the procedure under the same conditions. The perceived comfort rating was compared between the patient, the endoscopist and the endoscopy nurse. A total of 100 consecutive patients were evaluated; 55 chose to be sedated and 45 were unsedated. Of the 100 patients tested, 88% stated they would have the procedure the same way if a repeat procedure was required. There was no significant difference between male/female or sedated/unsedated patients. The most important consideration for patients who chose to have the procedure unsedated was the ability to speak to the endoscopist immediately post-procedure. Patient rating of pain was not significantly different between the sedated and unsedated groups. There was no significant difference in the independent assessment by the endoscopist and the nurse with respect to patient comfort in both the sedated and the unsedated groups. However, their assessment differed significantly from the patients own rating, as endoscopists and gastrointestinal (GI) nurses rated the patient degree of comfort as higher than the patients themselves (P < 0.01 for doctor/patient and nurse/patient score, Student’s t-test). No complications were reported in either group of patients during the audit. Unsedated diagnostic gastroscopy is perceived to be an acceptable alternative to a sedated procedure by the majority of patients. Patients rate the procedure as more uncomfortable than their health care professionals, but the majority of patients would still have the repeat procedure the same way.Unsedated diagnostic gastroscopy has become widely accepted as a diagnostic procedure which avoids the risk of an anaesthetic. It also provides advantages for patients and hospitals in converting the procedure to an ambulatory care investigation. Patient perception of the procedure can sometimes differ from that of medical and nursing staff. We have decided to report our usual clinical practice by auditing 100 consecutive patients undergoing this procedure in a large rural private hospital. Patient tolerance was analyzed in various categories including degree of comfort, degree of pain, ease of breathing and willingness to repeat the procedure under the same conditions. The perceived comfort rating was compared between the patient, the endoscopist and the endoscopy nurse. A total of 100 consecutive patients were evaluated; 55 chose to be sedated and 45 were unsedated. Of the 100 patients tested, 88% stated they would have the procedure the same way if a repeat procedure was required. There was no significant difference between male/female or sedated/unsedated patients. The most important consideration for patients who chose to have the procedure unsedated was the ability to speak to the endoscopist immediately post-procedure. Patient rating of pain was not significantly different between the sedated and unsedated groups. There was no significant difference in the independent assessment by the endoscopist and the nurse with respect to patient comfort in both the sedated and the unsedated groups. However, their assessment differed significantly from the patients own rating, as endoscopists and gastrointestinal (GI) nurses rated the patient degree of comfort as higher than the patients themselves (P < 0.01 for doctor/patient and nurse/patient score, Students t-test). No complications were reported in either group of patients during the audit. Unsedated diagnostic gastroscopy is perceived to be an acceptable alternative to a sedated procedure by the majority of patients. Patients rate the procedure as more uncomfortable than their health care professionals, but the majority of patients would still have the repeat procedure the same way.

Demonstrable professionalism: linking patient-centred care and revalidation

The move by the Medical Board of Australia to commence a conversation with the medical profession about revalidation reflects that patient‐centred care is at the heart of good medical practice. Patients judge their doctors’ commitment to them based on whether their individual interactions with doctors meet their needs. We argue that ensuring that doctors are continuing to perform at a level that the community regards as acceptable is a demonstration of an individual doctors professionalism and thus their commitment to patient‐centred care. This impacts on the profession as a whole, which needs to commit to what we call ‘demonstrable professionalism’ – the ongoing and active demonstration of performance that the community regards as acceptable. This needs to be supported by organisations in which doctors work, reflecting the importance of organisational context to clinical practice. Revalidation processes thus need both to reflect the work of doctors and be meaningful to the community. The move to consider revalidation of doctors by regulatory authorities should not be seen by the profession as a threat, but more as an opportunity to demonstrate the professions commitment to patient‐centred care.

Future of medical engagement

Although it has long been recognised that doctors play a crucial role in the effectiveness and efficiency of health organisations, patient experience and clinical outcomes, over the past 20 years the topic of medical engagement has started to garner significant international attention. Australia currently lags behind other countries in its heedfulness to, and evidence base for, medical engagement. This Perspective piece explores the link between medical engagement and health system performance and identifies some key questions that need to be addressed in Australia if we are to drive more effective engagement.

Medical management and leadership: a time of transition?

Perspectives on medical management and leadership are in a time of transition, but there is much we still need to understand better. This paper explores some of the tensions and dilemmas inherent in understandings of medical management and leadership.

Leadership in our health systems.

We welcome the editorial in the Internal Medicine Journal by McHardy and McCann on leadership in our health systems. This is an underemphasised issue, as health systems must continue to change in order to remain relevant to our communities, through ensuring effective care delivery. Effective leadership is critical in that meaningful change will not happen without it. There is uncertainty over the role of clinical leaders, and ongoing challenges in ensuring that clinicians are appropriately skilled. Clinical leader roles must be complemented by redesign of manager roles to ensure effective collaboration. The negative perception of non-clinical managers by clinical leaders remains problematic. The critical shortfall is, however, a lack of agreement on the purpose of our healthcare systems. Without this, the purpose of leadership in healthcare can never be agreed. Leaders must work to support alignment of organisational and clinician imperatives. Distributed leadership itself potentially inhibits reform, in that clinicians will tend to align with their clinical profession and its norms, limiting the ability to develop the networked and supportive workplace that is required to support real change. The purpose of leadership in healthcare systems should be to bring all stakeholders, including our patients, to a united view about the purpose of the system. Clinical leadership needs to be reconceptualised as a professional responsibility to ensure healthcare is reliable and effective. The separation of leadership and management is a traditional approach that we believe is no longer relevant to the complex adaptive environments of healthcare. Managers require leadership competencies to lead change during difficult circumstances Leadership and management are complementary systems of action with overlapping function and characteristic activities.

Modification of the National Inpatient Medication Chart improves venous thromboembolism prophylaxis rates in high-risk medical patients

Venous thromboembolism (VTE) is a significant contributor to morbidity and mortality in Australia. While there is well‐established evidence for the use of VTE prophylaxis in hospital inpatients, adherence to such guidelines is poor.