Monday, 6 June 2011


As a trainee in the hospital the best role models i saw had a proactive approach of following up the cases they were involved with. I believe in part this made them the high quality clinicians they had become.

Knowing the final outcome in cases you were directly involved, is the basis of one of the Work Place Based Assessment tools(WPBA) the Case based Discussion (CBD). For me reflecting on an interesting case and discussing this with a senior has been an enriching way of learning. It has changed my clinical practice for the better.

Politically, the NHS Outcomes Framework has shifted the focus to end results rather than processes. How these newer quality measures are incorporated into medical education and training, needs to be considered. I remember in medical school having to be signed off for doing X no. of procedures. There was no follow up about how long the venflon lasted for or how the patient felt subsequently days later e.g bruising, pain, infection. It is only when things go really wrong that we ever get things fed back to us.

The 'inbetween' stuff which is useful but not significant we dont seem to capture and feedback to fine tune our expertise. Outside the realms of WPBAs my experience is that proactive outcome based follow up isn't culturally the norm for most clinicians.

I have heard paramedics really curious about pts they treated for a CVA, A+E doctors curious but time poor of knowing what happened to their referrals and GPs like myself wanting to know the outcomes from my actions after referring a pt to hospital in or out of hours. We all want to know but the system makes it very difficult to find out.

There is a strong case for a system where these unreported facts about pt outcomes are fed back to those that have been responsible for their care. This makes sense educationally and training wise building on the WBPA on CBDs to raise the quality.

The concept of refection is already disseminated across the spectrum of medical education and the ability to use this skill with the final patient outcome is a strong combination to produce high quality training in a subject which ultimately is a vocation.

An ideal world for me in General Practice would be to have the facility to 'follow' interesting cases i have been involved with and receive a 'twitter style feed' of the pts journey via results of investigations, clinical encounters or written correspondence from the hospital which directly fed back to me until i stopped 'following'.This would enhance my learning in a time effective way rather than chasing the info.Furthermore it would provide a good solution for forthcoming revalidation to demonstrate clinical competence based on results and reflections from where outcomes haven't been satisfactory.

Unfortunately technical issues with IT that has haunted the NHS for years, info governance and diverse vested interests has made it difficult to create a joined up network of communication across all healthcare providers to facilitate this sort of feedback.

I think there is a strong case for this style of learning to begin if it hasn't done so already. What i would like to know is what research/evidence (if any) has been conducted to look into this aspect of education in a clinical setting.


  1. Welcome to the world of blogging! No turning back now:) I think this is a great idea and reminded me of this quote from Osler cited on Rakesh Biswas' blog
    ""Carry a small note-book, and never ask a new patient a question without note-book and pencil in hand...Begin early to make a three-fold category - clear cases, doubtful cases and mistakes. And learn to play the game fair, no self-deception, no shrinking from the truth; mercy and consideration for the other man, but none for yourself, upon whom you have to keep an incessant watch. It is only by getting your cases grouped in this way that you can make any real progress in your post-collegiate education; only in this way you gain wisdom with experience."(Osler 1904, 1928)
    I know what you mean by twitter-type update, ie short, but twitter suggests public and that wouldn't be appropriate. Any networks that carry information that could identify patients need lots of special security settings. That sounds very nontechnical-it is! I hope Mark Hawker will fill us in on terminology:)
    But the idea is really important. I wish I could even just flag up certain patient notes within our own GP record system to catch up with when I am next in. Patients could be made aware of who was following their notes .. Might be interesting to them.
    Thank you very much for sharing your thoughts.

  2. Great point, Akash. I too have learnt a lot from following up patients and that is easier in General Practice than in hospital. Although "interesting" cases do teach a lot, but many of my most blatant mistakes are made with a Coyote-like confidence (see Kathryn Schulz's TED presentation A system to pick out these moments of error-blindness would be great for learning. What do you think?

  3. @Ann Marie

    Thank you for reading and sharing my blog with others. Great quote by Osler.I wonder what his take would have been about eportfolios and revalidation if he was alive today.

    I take on board your perception of the word 'twitter style' and info governance concerns. It was only meant to be a metaphor to explain my concept. In my 'vision' the feed would be truly integrated into EMIS or the equivalent EMR system.So when the clinician logs in for surgery you have section which addresses this. You could then switch to the patients notes if necessary to remind yourself of details in the same program. There is nothing more irritating then having to switch between 4 different windows on a regular basis!

    At present we have access to our patients blood and radiology via a separate internet connection and two different usernames and passwords.It is a bit fiddly and you cant transfer results for sake of QOF etc and avoid duplication.

    From a patient perspective, virtually everyone i have spoken to have been in favour of the concept. At present they expect me to know what has happened to them in hospital but sometimes i don't know until they bring me the discharge form at consultation. They get very frustrated by the fact that what has happened to them has not been efficiently communicated across boundaries to the people who need to know.

  4. It's interesting that we're seeing a lot Of talk about machine learning now. Have you seen the discussions about Watson? It seems that much of expertise in medicine is about pattern recognition and we need feedback to know what those patterns are. Thanks again for sharing:)

  5. I haven't seen any discussions about Watson...please send link if you have. Yes agree about pattern recognition. Technology assisting with that i'm all for. As long as machines are servants to us, and not the the other way round, then i'm happy!

    A physical metaphor for someones personal learning need is like clothing, such as a suit or scrubs. We're all different shapes and sizes so a generic 'one size fits all' doesn't fit well for a significant number and only adequately at best for the others.

    I think the 'twitter style concept' can give a tailored fit to peoples unique learning/development needs and acknowledge there are differences. It will give clinicians the choice to focus on cases/subject areas, based on where they feel they need to develop a better pattern recognition.

    Starting GP and having not done paeds i used to get very stressed when trying to identify the 'sick' child. I wanted to gather evidence to prove to myself that i was sending the right ones home and the sick/potentially sick to hospital.

  6. @halfbakedpotatoes

    I really liked the video.It would be interesting to know in what context the mistakes were made in.I'm assuming clinical? Your question is very difficult to answer. I suppose it depends on why you ended up being wrong in the first place i.e. not listening properly,human error,system error or a rare diagnosis that anybody would have struggled to spot.This i suppose you reflect on and hopefully learn for the future by putting in down to experience especially if you operated on the wrong leg!

    We all accept humans aren't perfect and make mistakes.Having a personal and organisational system which acknowledges this fact and manages this risk would be a suggestion.

    A really good book called 'I don't know what it is but i don't think it is serious' talks about different hats you wear when consulting. I try to be reassuring as i can where appropriate but even when i am really sure i never give 100% certainty(Lawyer/politician hat)as i know over a career there will be a time i will be wrong when i was sure i was right.

    It's a nice buzz to provide reassurance and take worry away from patients but i think it boils down to how often you think you will be wrong when you thought you were right and how severe the resultant mistake would be.

  7. Really interesting post. Thank you.

    As a GP who used to be a partner, but is now a locum, I have a heightened recognition of the difficulty of getting feedback. Locum GPs have very little continuity of care. Consequently feedback happens very infrequently.

    I remember receiving a card through the post, forwarded by a practice I'd recently worked in. It was from a patient who had arthritic fingers and thumbs. At the time I had read the NICE guidelines promoting the use topical NSAIDs in OA and suggested this to her.

    She wrote "...I could tell that you may not have been totally convinced the treatment would help me much, but it was nothing short of miraculous - and with no side effects! I wanted to let you know so that you could use my experience to help others".

    Enouraging patients to play an active role in providing us with information about outcomces and feedback is is a very low-tech solution to the problem. I invariably ask patients I admit as emergencies to let me know as soon as they are discharged. But difficulties in getting to see the doctor of their choice gets in the way of this.

    Continuity of care is a highly valued aspect of UK General Practice. Knowledge of a patient, his family, his life, his background, his psyche - and what happened to him through an illness - was easy back in those days when many GPs were single-handed practitioners and continuity of care was the norm. I am often struck by how difficult it is in some of the practices I work in to achieve any sort of continuity. But some manage it better than others.

    While a sophisticated e-solution to the problem is very seductive, I think we should in the meantime focus on learning from those practices that manage to provide the continuity that our patients (and we, the GPs) really desire.

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  9. Dear Akash

    Thank you for highlighting these important issues - it was ironic that meeting you at the Clinical Leadership Conference that I learned that the frustration faced by paramedics and indeed ambulance services from an organisational perspective are shared by GP colleagues too.

    It has been a source of immense frustration for me, throughout my clinical practice, to not be able to find out how my patients are getting on, both in the short and longer terms. I haven't been able to understand the outcomes from my clinical decision-making and in short, much of my clinical practice over the years has been performed blindfolded - in terms of the ability to learn from my previous actions.

    You rightly highlighted stroke cases - but of course it applies to almost all types of cases.

    I remember early on in my career as a paramedic, I called through to an ICU (where I had taken a patient 24hrs earlier) and asked to find out how the extremely poorly patient I had managed pre-hospitally was getting on. I understood the needs of patient confidendiality and information governance, but from a human and clinician perspective I wanted to know what had happened. The call was passed from doctor to nurse and back again and eventually I was told nothing..........on reflection, I realised that I could have been anyone and their circumspection was wise.......I decided that I would seek feedback in person next time - which isn't always possible as you can refer/transfer to multiple geographically disparate services during the course of a single shift.

    On another occasion, I had treated and managed a patient, who similarly ended up in ICU and a couple of days later I popped into the unit to see how progress was. The patient was doing well, but the team were really concerned about a low hb and that they had needed to transfuse the patient - when I discussed the case with them, I was able to disclose a significant bleed at the roadside, which although I had recorded in the ambulance clinical record, had been lost in translation from A&E to ICU. So there's clearly a case for joined-up care.

    As a clinical leader in my organisation, I have been responsible for setting up a number of clinical care pathways, ranging from stroke and ppci to trauma. One of my greatest frustrations, alongside that of being a clinician who can never find out about the patients I treat (almost never), is that in working with colleagues from across disciplines and organisations, we have setup pathways for which the ambulance service can not consistently and accurately measure the system-wide outcomes for - are the pathways good or bad, are more lives saved or not?

    You could argue that ~£1billion is spent each year in the UK ambulance services, and save for measure the care delivered at the time - we don't really know what happens or how effective the care is for a majority of these cases!

    Most patients I have dealt with are really keen to support us all as clinicians in learning and really don't understand the flow of information - being that it can only go in the direction of patient care. Most paramedics don't revisit the same patients, nor have a role in ongoing have no right to the information.

    I would like clinical feedback as an individual and as an organisation and I believe that most patients would support this - after all they want to know that we're continually getting better.

    Thanks for raising this issues, lets think about how we lobby getting things changed so we can collectively improve patient care and outcomes.