Download PDF: FL Communiqué April 2019
Case: The eyes don’t see what the mind doesn’t know
Subspecialty medicine: Time to ask the experts
Can a focus on relationships help prevent tragedy?
Comments from our peers
Welcome to the April edition of the Future Leaders Communiqué. As return readers will know, each edition of the Future Leaders Communiqué presents cases of preventable health care-related deaths and explores the systemic issues and errors identified in the ensuing coronial investigations. All junior medical officers (JMOs) working in a hospital setting will relate to these issues – I’m sure we can all recount a ‘near-miss’ situation that has stuck with us and informed our day-to-day work. Similarly, the aim of these discussions is to raise awareness of the potential failures or gaps in our system and provide some tools for which to overcome them. The overall goal being to improve patient care and safety in all settings of healthcare.
This edition will explore the concepts of compartmentalisation and subspecialisation in medicine and their impact on inter-specialty relationships and collaborative care. These issues are implicit in the case of a young woman’s avoidable death due to ventriculoperitoneal shunt dysfunction. This fatal pathology went unrecognised over several presentations to a tertiary teaching hospital despite the relevant investigations being reported as abnormal. Specialty bias led to misinterpretation of the imaging findings, while miscommunication between specialties resulted in a missed opportunity for the appropriate involvement of a neurosurgical specialist.
We are working in the era of an increasingly complex healthcare environment. The achievements of the past 50 years have led to improved health outcomes globally and an ageing population. As a consequence, we are often caring for patients with complex medical issues for which we have a multitude of treatment options and pathways. This has in turn necessitated our healthcare system to become ever more subspecialised and compartmentalised. In his 2012 TED talk Dr Atul Gawande summarises this evolution: in the 1970s inpatient care consisted of the interaction of only two clinicians – one nurse and one doctor. Thirty years later the same patient episode would involve at least fifteen clinicians and subspecialists. As Dr Atul Gawande puts it, ‘we’ve reached the point where we’ve realised, as doctors, we can’t know it all. We can’t do it all by ourselves.’
It is therefore inevitable that while working as individuals and in teams, we will reach the limit of our experience, skill-set or scope of practice. This is especially relevant to JMOs rotating frequently through various specialties or moving into roles of greater responsibility. As a resident doctor learning to assess patients independently I would always run through the issues list with my supervising registrar, just to be sure I hadn’t missed anything. Different experiences and perspectives might result in something being glaringly obvious to one clinician but completely missed by another. This is the focus of the cited article published in the Harvard Business Review which highlights the importance of creating environments that ‘support perspective sharing and effective communication’. However, this is easier said than done.
The increasing compartmentalisation of healthcare has caused a change in the relationships and cultures within and between specialty teams of doctors. I was interested to find a growing commentary on this topic, particularly regarding the impact of ‘tribalism’ on collaborative patient care. Tribalism refers to strong bonding within a group which maximises team loyalty and identity. While this can be beneficial within teams, Hewett et al found that strong specialty-based identity often created conflict and tension between specialty units, and can significantly impact the quality of patient care and safety.