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I'm a radiologist and writing helps me make sense of the world.

"My method is to take the utmost trouble to find the right thing to say, and then to say it with the utmost levity" -George Bernard Shaw

Tuesday, 30 August 2011

Reflection on Reflection

Our dear Royal College has decided to formalise, nay, mandate reflective practice from every Fellow. It is now embedded into ongoing professional development. This news may have completely passed you by, but this is official as of 1st Jan 2011. We are now required to provide evidence of reflective learning. More specifically, this is required by the RCR for “online CPD activities (and all Category II CPD activities)”. We are not alone, the RCR is one in a long line of UK Royal Colleges who have introduced such a system.

Some will have read this and made a PFFFFFFFTT noise as they involuntarily spat their drink across the room. This is quite understandable. Working in the NHS inexorably turns innate medical scepticism into abject cynicism. And the longer one works in the NHS, the more hard-bitten one becomes. Hence anyone pushing a particular way of thinking, behaving or working in the NHS comes in for a hard time, particularly when extra work is being proposed. At best, such idea-mongers are viewed with an arched eyebrow and pursed lips as we attempt to discern their hidden agenda. At worst, there is open hostility with, shall we say, lapses into the vernacular.

Reflective practice is considered a Good Thing. Educational mantra has us believe that critically looking at our emotions, experiences and actions can lead to valuable insights. It follows that such revelations about our strengths and weaknesses can only lead to improvement.

Reflection has the oldest of educational roots. Socrates boldly stated “the unexamined life is not living”, believing the sole purpose of life is personal and spiritual growth. His method of self-examination through dialogue has stood the test of time. Modern notions about formal reflection are founded on an extensive literature spanning four decades. Reflection is heavily emphasised in educational circles: go on a Teaching Course and you’ll not only learn the names of Schön & Kolb but also be expected to spend time metaphorically navel gazing.

Many doctors think little of reflection. Some are openly hostile, convinced it is an utter waste of time; tree-hugging nonsense for folk who don’t know what they are doing. Some are ambivalent; they can see possible merit but don’t do it and resent being told to do so. Even those who espouse its benefits secretly rarely engage in formal reflective practice.

The author hugs a tree

Amidst this angst and politics lies a paradox; reflection itself cannot be reflected on. It has gained such pre-eminence as an ideology that it cannot be questioned; it is now firmly part of the educational hegemony. Anyone daring to question its importance is seen as a scholastic luddite, a pedagogical heretic and educational dinosaur. Not a good state of affairs.

However, there are serious and weighty criticisms of reflective practice. For starters, if you spend all your time examining your life, you leave no time to live it. One analogy is driving whilst always looking in the rear view mirror. This is a very real problem; if reflection is overtly emphasised then it paradoxically inhibits learning.

Another persistent problem is how to define reflection. Critics have said that it is indistinguishable from “thinking”. Which we all do. If a term can mean anything, it means nothing.

The other worry is overvaluing the products of reflection. Solipsism (the view that the self is all that can be known to exist) can lead to some seriously distorted or even frankly wrong views. Such ‘bad’ knowledge can drive out the good. One analogy here is that spinning your wheels in the mud is more likely to lead to entrenched ruts than real progress.

Whilst this debate may (or may not) be incredibly interesting and entertaining there is a trump card. One of the fundamental flaws of reflection is the absolute lack of evidence that reflective practitioners are any better than their peers. Quite why this should be is a matter of debate. There is some evidence that reflection is a symptom of good learning; an epiphenomenon. Hence it should not be a goal in itself.

The RCR should be bold - drop mandatory reflection in professional education. The contribution of reflection is marginal, it is ideologically driven, and sometimes counterproductive. As experts in our field, most of us have got there quite happily without the need for formalized reflection. And we certainly don’t like to be told to do something with no evidence behind it.


Credit - I am very grateful to James Atherton for this very wise article, ironically providing much material on which to reflect.

Friday, 1 April 2011

MDTs and the Bourgeois

Site-specific cancer multidisciplinary team meetings (MDTs) are a prominent feature of the working lives of all Fellows of the RCR, radiologists and oncologists alike. We attend them dutifully yet we rarely question anything about them. OK, we moan like hell when they don’t run smoothly but that is about it. I contend there are aspects of MDTs that are strikingly unusual.

First is the love: hate feelings that MDTs engender. On one hand, few relish them. They are tolerated at best, made passable by decent colleagues. Part of this is their reputation as a time-occupying lesion; the preparation and attendance takes most of a session. A degree of scepticism is warranted: the cost of running a single MDT is approximately £1000 per hour in wages alone.

On the other hand, by improving communication they undoubtedly improve patient care. If a loved one were to sprout a nasty, we would want them discussed at a well-run MDT complete with a full array of experienced specialists.

Second, MDT is a misnomer. A victim of political correctness, you might argue. Rightly or wrongly, doctors of various specialities dominate the discussion. Others occasionally chip in but rarely do so despite more than a passing nod to egalitarianism. A Clinical, Radiological And Pathology meeting would be more accurate but the acronym is rather unfortunate.

Third, relative contribution is changing. In meetings of yesteryear, the radiologist hinted at a vague mass on blurry images from a relative barbaric contrast study. The physicians stroked their chins, postulating a hepatorhubarboma. The surgeons hacked it out via a 2-foot incision. The stage was then set for the pathologist to step up and administer the coup de grace. Case discussion was not over ‘until the pathologist sings’.

This is becoming less true. The radiologist often makes the diagnosis without physically laying hands on the patient - they now sing the harmony, the surgeon joins in on the chorus and the pathologist merely hums along. Then the physicians applaud effusively at the end. Although we all smile and nod at the pathologist, it isn’t clear what tune they are humming. Or if it is even a tune at all.

Last, I’ve observed several stereotypical but undesirable behaviours in the MDT room. Perhaps some sound familiar:-

- The Dylan Thomas. This person is an undoubted talent but also a loose cannon. As Clive James writes, “ ... there will always be a Dylan Thomas, and he will often do great things, even while borrowing more money that he earns, breaking his bargains, drinking the pub dry, pissing in your fireplace and wrecking every life with which he comes into close contact.”

- The Blatherer. Every time this person opens their mouth, everyone’s hearts sink. Often perfectly competent, their lack of succinctness and frequency of contribution diminishes everyone’s opinions of them.

- The (Ex-)Surgeon. This person has bimodal dress; either a suit / tie or scrubs. They prepare briefly yet meticulously. Unlike the Blatherer, they like it sharp and snappy: their differential diagnosis rarely reaches 2 conditions. Their sense of humour is so bone dry that most people think they don’t have one.

- The Hedger. In contrast to the (Ex-)Surgeon, this person sits so firmly on the fence that their backside is peppered with splinters. Their fear of being wrong robs them of the joy of being right. Their typical response to a question is to ask several questions in return. Whilst caring people, their lack of confidence and worrying about missing anything is ultimately their downfall.

- The Joker. Whilst usually a quite able individual, they love deviating from the matter in hand with humorous intent. There is a balance here; clinical abilities can be overshadowed by incessant buffoonery. They also run the risk of overstepping the line, causing offence and making a fool of themselves. Hence the Joker can become a paradoxical joke figure.

- The Git. This superficially charming but fundamentally oleaginous individual is bright and knows it. To them, modesty is just a seven-letter word beginning with ‘m’. They see MDTs as a sport where points are awarded for exposing the intellectual deficiencies of others whilst concealing their own shortcomings. Double points are gained for humiliating those more junior to them. These individuals tend to have several CEA points.

Several of these character traits are superficially enticing. Doesn’t everyone dream of breaking our behavioural shackles, perhaps becoming the latest Dylan Thomas of the MDT world? However, if we all did this, UK oncological practice would implode in a cataclysm of antisocial behaviour. Realism should prevail. I’m with Gustav Flaubert who famously wrote that, “One should live like a bourgeois, think like a demi-god”.

Monday, 24 January 2011

On Being Ordered

My trust is about to introduce a new Hospital Information System. Being an earnest sort, I accepted an invitation to go along to a 2 hour briefing session specifically aimed at consultants. The audience were uncharacteristically lively; both of us asked a number of questions. The system looks very good and will undoubtedly be huge improvement. I’m not saying our existing PAS system is old but the Science Museum have said it is of historical significance and could they please have it when we’ve finished with it.

One aspect of this briefing did stick in the craw a little. It isn’t overtly pedantic. Well, okay maybe a little bit. But it rankles; neither spitting bile nor throwing-toys-out-of-the-cot but a jaw-clenching, finger-drumming, 10mmHg-systolic-rise type issue.

It is over the issue of “ordering” versus “requesting” of investigations. Now some people couldn’t give two hoots if it is a request or an order. I contend they are quite, quite different words. Similar, yes, but they have very different origins, connotations and subsequent implications.

A “request” is an entreaty, a polite and formal way of asking for something, a gentlemanly wish, an invitation, possibly involving discussion of the finer aspects. It comes from the Latin “requirere”, from re- (expressing intensive force) and quaerere “seek”.

“Ordering” is something else entirely. It is a unidirectional demand, a consumerist command, an authoritative diktat. Its etymology is quite different, from the Latin “ordinem” meaning “row, series, arrangement or rank” in secular, honorary or military orders. Its meaning of command is purely from the notion of “to keep in order”.

Many institutions have electronic radiology requesting. To some, paper requests seem quaint and faintly nostalgic. I did hear of a hospital that kept having to replace the computer screens in fracture clinic. Apparently the Orthopods keep scrawling on them and our PACS people can’t get all the crayon off.

Well, Order Communications or “Ordercomms” is the accepted technical description of the broader church of electronic requesting. Our dear College have just released a guidance document about how they should work. It is quite technical; I read it thoroughly and even understood some of the words.

I don’t think I’m being prissy, but being indirectly ordered to do something gets me rather hot under the collar. Whenever I hear a doctor saying the words “I’ve just ordered…”, I can’t help interrupting with a terse “No, you’ve just requested...”.

Junior doctors used to arrive with request card in hand, saying, “Can I discuss a case with you?”. Now it is a telephone call saying, “I have ordered this scan, why hasn’t it been done yet?”. I used to think that this change in behaviour and language was because most junior doctors learn most of their trade from watching episodes of House and re-runs of ER.

Perhaps Ordering is quite apt in the American setting. The relationship between clinician and radiologist is different, medical practice is different and the commercial aspect of medical practice is a factor. However, this model of practice isn’t appropriate for the UK NHS and it isn’t necessarily better.

Individual case discussion between radiologist and clinician is at the heart of good medical practice. The more complex and the more sick the patient, the more discussion there should be. The patient gets the right sort of scan, at the right time and the clinical question is answered. When I say radiologist, you could substitute any other speciality in there; when I say scan, you could similarly substitute any opinion, investigation or therapy.

I am convinced that this slide away from requesting to order has perniciously warped clinical practice. Not deliberately, mind. I don’t doubt that Ordercomms can streamline clinical work but it can inadvertently encourage the crucial discussion step to be skipped. Moreover, avoiding such discussion gets to be seen as an advantage, a positive benefit of the system.

Without discussion, the clinical question remains ill-defined, the patient often gets the wrong type of scan at the wrong time. The clinical picture is muddied; further investigations are often required to tidy up the mess. It wastes resources, delays management decisions and is fundamentally Bad Medicine.

So, when your hospital installs a new system, don’t settle for anything less than a system that facilitates “requests” and aids clinical discussion. It isn’t raging against the dying of the light, it is fighting US corporate hegemony and standing up for Good Quality British Medicine.