Medic One Funded Projects
MEDIcal DEcision making & diagnostic error
I am currently an ST4 Emergency Medicine Trainee in Edinburgh. During the month of June, I was lucky enough to spend a month in North America, focusing primarily on medical decision making and diagnostic error. I spent the majority of my time in Halifax, Novo Scotia, in Canada with Dr Pat Croskerry and Dr Sam Campbell. Pat Croskerry is a world leading expert in patient safety, critical thinking and medical decision making. I spent time in the main trauma centre which sees around 230 patients a day; and also a district general emergency department.
‘Emerge’ as they call it in Canada, is in many ways very similar to the UK: health care is free at point of care and the spectrum of health conditions is similar to what we see in Edinburgh. People have a similar sense of humour, and yes, Canadians really are very, very nice! There were a few big differences though. The biggest difference was the lack of a 4 hour target. I thought this would be refreshing to work within, but over my time there I came to appreciate aspects of what the 4 hour target achieves in a way I never thought I would. We may have problems with bed blocking and waits for hospital beds, but our waits tend not to stretch commonly to 2-3 days and beyond. There is little drive for the wards to create space to admit the new patients. The knock on effects of all this mean that the wait for assessment is often substantially longer than in Edinburgh.
Other differences that I observed were that, generally speaking, fewer tests are ordered; and that the environment is a nicer space to work within due to the ‘pod system’ which creates a separated central area for staff, free from constant interruptions and beeping machines. The fridge freezers containing ice creams and other treats helped too!
In addition to clinical time on the shop floor, I attended various morbidity and mortality meetings, the Canadian Patient Safety Group Course, resident simulation sessions which are performed using cadavers and had various meetings with clinicians and educators involved in the critical thinking movement. Most invaluable was the time I spent with Pat discussing the theory and how we put it into practice. I stayed with Pat and his wife for a week and had many interesting and entertaining conversations from which I learnt a lot, as well as getting to know two lovely people.
I was also fortunate enough to travel to Pittsburgh, Pennsylvania, for a week to spend some additional time with Dr William Follansby and his team who have developed and implemented a curriculum in medical decision making which is delivered to all medical residents and final year medical students. The differences in practice of medicine in the UK and the US are huge but this was a really useful week which generated a lot of ideas of how we can better teach decision making in our practice.
Diagnostic error is estimated from several big studies to be as high as 15% in the Emergency Department with the majority of errors resulting from cognitive errors, that is, mistakes in the way we think and make decisions. This can have big consequences, including deaths which could have been preventable. Initiatives we have like ‘Zero Harm ED’ and an open culture to discussing mistakes are steps in the right direction. In Edinburgh we have a good ethos for continued improvement and reflective practitioners who aim for the highest level of care. We have a really good department but my time in North America consolidated the importance of better understanding how we think and why errors occur, in order to continue to provide the safest care possible.
It gave me a lot of food for thought and I hope to be able to share what I have learnt in more detail over the next few weeks, months and years. In particular, I hope to develop ways of teaching medical decision making and cognitive error within our department.
Looking back, I had an amazing time and met a lot of wonderful people - Canada is a fantastic and beautiful country. A big thank you goes to all the people who made me so welcome. Many thanks as well to the Deanery and department for allowing me the time to do this. A final big thank you to the Medic 1 Trust Fund for the donation of £500. Without all of this it wouldn’t have been possible.