more_vert
MANY readers will have heard the old aphorism “those who can, do, and those who can’t, teach”. This saying seriously underestimates the value and skill of teaching, not to mention the Hippocratic obligations in medicine to do both. So, I would like to propose my own version: those who neither do nor teach should be cautious about criticising those who do.
This comes to mind due to a confluence of situations which, in my observation, contribute to the pervasive malaise that affects many parts of the health workforce at the moment.
First, there are well intentioned but poorly executed risk management systems, including that tool of the quality and safety industry known as the root cause analysis. Applied with insight and in situations where there is an identifiable root cause for an incident, the resulting recommendations can assist in prevention of future occurrences. Hopefully, this will occur without causing other sidestream harms worse than the ones being mitigated.
Applied inappropriately, however, as may be done when teams are unskilled or lack insight into the work process, they can be another tool for blame and result in yet even more cumbersome procedures. A health care workforce labouring under conditions of fear and overburdened by “risk management” procedures will not be able to use their skills for optimal patient care. More sophisticated tools for clinical risk management do exist, including the so-called London Protocol.
Next, there is the frequent bombardment of “conventional medicine” by the non-conventional – those providers who hold little responsibility for their advice, products or outcomes, and yet constantly criticise those of us who do. In selling their services or their wares, many “alternative” health care providers use a constant critique of conventional medicine, diminishing its benefits and exaggerating its harms. Ethical providers may be frustrated in finding that those who sell simplistic, magical solutions may be held in higher esteem than those who do their best to convey accurate, evidence-based advice.
Finally, there are those within our own profession who provide expert advice on the performance of others. This may occur in the workplace, in the regulatory system, or for the courts. We all know of a minority of people who are too ready to hold colleagues to standards that they have never met themselves.
The safe and ethical practice of medicine requires constant self-reflection, sharpened by an understanding of cognitive science, medical science and emotional intelligence. The same approach is needed when appraising the work of others.
In my view, the question we should ask ourselves is not just “what would I have done in that situation?”, but also “what HAVE I done in that situation?” If the answer is that we have never directly experienced it, or have never been held to account for the outcome of such a situation, we must be very careful in judging the actions of those who have – especially with the benefit of hindsight.
Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. She is an executive member of Friends of Science in Medicine.
To find a doctor, or a job, to use GP Desktop and Doctors Health, book and track your CPD, and buy textbooks and guidelines, visit doctorportal.
Loading ...
Mindfulness. An antidote for pervasive malaise in healthcare?
In her article “Self-reflection-science-and-emotional-intelligence-in-medicine” Dr Sue Ieraci has suggested there is a “pervasive malaise within healthcare”, fed by hype from purveyors of non-conventional medicines and low levels of metacognitive virtues within the workforce, contributing to a culture of “blame”, social friction and poor policy decisions in healthcare.
The recommendations of self reflection and contemplation are welcome, however it should be noted that these capacities arise from within a broader set of metacognitive abilities, particularly the critical process of self regulation. Surprisingly no mention was made of the evidence base for interventions that specifically enhance insight and redress malaise, underpinned by changes in metacognition and self regulation, notably those of mindfulness based interventions (MBI) and other related meditative techniques. e.g. MBSR, Vipassana. These are areas of considerable research interest in the disciplines of cognitive science, medical science and emotional intelligence amongst many others.
Self regulation is the ability to develop and practice integrated awareness, feeling, behaving and relating more skilfully. MBI’s enhance this, with evidence for improved mood, insight, empathy and self reflective capacity, via an ability to regulate attention, behaviours, feelings, thoughts, and social relationships with greater clarity. Changes occur at both neurophysiological and psychological levels, integrated by the important neural networks of the connectome, including interoception. MBI practices result in plastic changes of mental and brain functions related to arousal/physiological/subconscious processes, body awareness (interoception), attention regulation, memory, emotion regulation and self-perspectives. Alterations in predictive coding responses seem to underpin much of these.
In summary MBI’s address top-down integrative functions in the same brain networks that are involved in regulating the stress response, constructing emotion and the experience of self and relatedness. Downstream effects are found in all areas of personal human experience but also in the dynamics of social relationship and this very much includes the workplace. The prosocial emotions of others provide the neurobiological cues for our own cognitive and emotional generosity, compassion and prosocial behaviours. Workforce temperament, resilience and performance outcomes are always affected by the individual and organisational dynamic.
Opinions and generalisations should always warrant self reflection, yet rarely appear to do so, and it seems that cognitive errors of premature cognitive commitment are commonly found in opinion pieces. First described in learning psychology by Langer 1989, premature cognitive commitment is the process of thinking and acting from a position which we already believe is true. The subjective validity of medical approaches based on convention should be no exception to self examination. At its heart premature cognitive commitment is as much a learnt subconscious neural cognitive process as much a psychological result, and is considered to hold the opposite attributes to highly efficient self regulation including reduced flexibility and curiosity.
Work in cognitive science and emotional intelligence is in part currently focused on understanding the workings of consciousness, in particular the critical regulatory systems of the mind in relation to not only individual health but to actual lived experience, including the neurobiological basis of beliefs, social relationship and MBI’s. Neuroscientist Lisa Barrett Feldman, one of many integrated thinkers in the field writes: ‘Our ideas about emotion (and really all human experience) are dramatically, even dangerously, out of date – and we have been paying the price. All cognitive constructs including emotions don’t exist objectively in nature, and they aren’t pre-programmed in our brains and bodies; rather, they are psychological experiences that each of us constructs based on our unique personal history, physiology and environment.” Our phenomenal experience is irrevocably hard wired to our physiology, change in one cannot occur without changing the other.
Thus it seems MBI’s with their non conventional origin, progressive concepts and at least 3000 years of documented contemplative tradition are likely to provoke feelings of ontological discomfort in the skeptic. However there is now a broad base of evidential support and consistency across many fields as diverse as neurobiology, research into mental and somatoform illness, developmental psychology, ageing and chronic pain, sociology, psychiatry, and public health.
A similar example of premature cognitive commitment arose from Dr Ieraci some years ago when the existence and possibility of the microbiome/gut barrier as an unrecognised potent bottom up driver of systemic inflammation was wholly and publicly dismissed. Whilst observations of and applications to alter the gut microbiome was developed in non conventional medicine only about a 100 years ago, mindfulness based neurobiological metacognitive integration has several thousand years of practical application. The example of MBSR with hundreds of clinical studies that is now increasingly validated by mechanistic cognitive science & neuroscience is a case in point.
Progressive medicine then is neither non conventional, nor alternate, it is not dissonant chiropractic or flakey energy healing, but one based in modern evidence based neuroscience and embodied psychology, with supporting evidence from traditional practices in many cases.
That there is a “pervasive malaise” in health care is really no surprise, for we are seemingly being instructed from within a perpetual Cartesian hangover. Stalwarts of 20th century medicine are teaching from the model they themselves exist in and write from, one that has never found comfort with a complex systems based approach. The results are clinicians operating from an outdated system, and an experience that often fails patients and providers alike. It is no wonder patients are sucked into fringe medicine, where hope may be the only clinical tool that has any efficacy.
Considerable evidence now exists for MBI’s. Increasing our capacity for self regulation appears likely to be able to directly help what is being noted in the “workers complaints of (being) unskilled or lacking insight into the work process”, simultaneously benefiting the immediate social psychology of the workplace but is also resulting in an improvement of the patient experience of health interventions. Perhaps turning toward a more curious mindful approach from within ourselves as healthcare workers would result in improved resilience and insight in the workplace, an anti-malaise building antidote.
Dr Paul Stevens is a registered medical practitioner, lecturer and a mindfulness meditation teacher with over 25 years experience in clinical and mind-body medicine.
Thanks for such a thoughtful article, Sue. I was particularly interested in your mention of alternative methods of risk management. At the moment it seems that what some managers are referring to as risk management is really complete risk avoidance, which of course is not possible in health care, and anecdotally seems to be increasing costs without improving outcomes.
It’s impossible not to make mistakes in medicine – we are human beings, not made with perfection in this realm. As a current medical student, there is also the constant process of reflection on how one has performed in each and every situation. It’s very easy to throw eggs from a position of relative comfort, protected, as we are, from the responsibility that apparently lays with our many teachers and clinicians. But in a few short months, I will be amongst you as one of your colleagues, and long may that self reflection continue. In that light, I cannot see how current student colleagues’ tendency to throw stones will abate upon graduation. There is a long legacy of not taking responsibility for our personal and if not professional actions (“I’m just a student”). We are responsible for our learning, but there must surely be an adjustment for us to learn, en mass, how to step up to the responsibilities delivered to us as human beings doing medicine, with all our imperfections and challenges yet to master, instead of passing the buck up or across the line to criticise others.
An anaesthetist once told me that if he wanted to get out of doing an obstetric epidural, he told the patient there was a 1 in 100,000 risk of paraplegia (which is apparently an appropriate figure.)
Many of the quacks whom you disparage, Sue, use similar tactics both to dissuade (may cause autism) or seduce (may help immune system support). But I suspect the ‘pervasive malaise’ may be a result of too much self reflection on minutiae. Narcissus didn’t get anything done.
As Hamlet put it:
Thus conscience doth make cowards of us all,
And thus the native hue of resolution
Is sicklied o’er with the pale cast of thought,
And enterprises of great pitch and moment
With this regard their currents turn awry
And lose the name of action.
In cases like that of Dr Bawa Garba, she made a diagnosis and instituted treatment, then changed her diagnosis/treatment after receiving updated test results, which arrived too late to save the child. Her reflections on her management were used against her in court. However, the blame process does not help the next doctor in that situation to make a better decision, only to feel more vulnerable. Or worst of all, to consider Hamlet’s ‘bare bodkin’ as a solution.
Good points made through-out; only one I should mention…Hippocrates was a pagan,worshipping all the gods the
Romans tried to appease,and even today pagan-worship takes place on the Island of Cos !
Pity he did not know the One,True,Living God….The God of Abraham ,Isaac and Jacob !!…………….rob.the.physician
Thanks Sue. Loving the new aphorism! I’m grateful every day that I am both doing (geri med) and teaching (course coordinator for one uni course). That said, there is an endless supply and stream of critics and snake-oil sellers in life generally, and unless I’m mistaken, it appears to be a universality in any sphere, perhaps even human nature (we seem to love outrage… eg look at the ball tampering reaction recently). Nevertheless, this needn’t mean we have to let ubiquitous handbrakes impede forward progress. Teaching core concepts and enthusiasm to young people may be one antidote to pessimism, and may hopefully get more clinicians to be aware of what is data-free nonsense and what isn’t, all the while maintaining the key humility underpinning science: “we know that we don’t know everything”. We can still be upfront with this, and use it to drive genuine ‘non-magical’ progress.
It will be extremely interesting to see what the results of the poll are.
I suspect that the result will be be in the affirmative.
The question then is how we best reflect. Julian Archer (head of the Collaboration for Medical Education Research and Assessment to Plymouth University) spearheaded a report on this for the Medical Board of Australia recently. He believes reflection has most impact when we have concrete data to base that reflection upon. That data set can be comprised of many different metrics, including objective outcome data, self assessment and peer / patient feedback.
The data needs to be creditable, objective (where possible), quantifiable and relevant to our perceived needs.
Finally, where possible, it has more impact when facilitated, because as good as we believe we are at self-reflection, we all need a helping hand sometimes.
How many of us achieve this standard currently?
There’s a good podcast with Marcus Watson from the Skills Development Centre in Brisbane on this topic too : https://omny.fm/shows/osler/how-do-we-learn-skills-in-clinical-medicine