Invite, Include and Involve…

I can think of a few profound occasions where my decision making was fundamentally changed by inviting, involving, and including the patient or trainee.

Patient

I instituted a Fit to Admit clinic to consent and set expectations for elective admissions – this resulted in significant clinical and operational benefits that have since been published. I recall a gentleman aged seventy-four, impeccably dressed in blazer and tie. After confirming his history and carrying out a thorough-head-to-toe examination, I was in the process of confirming consent when I was interrupted by the question “Doctor…do I really need this operation?” He went on to explain that his symptoms were stable, and he was not really troubled in daily activity. Having further explored the history and understood what mattered to the patient, I concluded that the patient had a point. In ordinary circumstances this patient would have inexorably ended up on a ward in a gown the night before surgery having consented to a major operation without an opportunity to be involved, included and, more importantly, to challenge what had been deemed by the system as necessary.

This is beautifully summarised in ‘prospect theory’ described by Daniel Kahneman. He described the decision process in the form of a graph. The y-axis represents the probability of outcome of a decision of doing something (above the x-axis) or doing nothing (below the x-axis). To me, the y-axis, reflects the evidence base of the decision to operate or not to operate and thus the domain of a consultant surgeon. The patient will interpret the probabilities of outcomes as well, but it is highly likely that due to communication, comprehension and individual biases and heuristics that the perception will be different. The x-axis records the utility or worth of that decision. We should remember that the utility or worth of the decision is entirely up to the patient. It is what matters to them! Gone are the days of ‘doctor knows best.’ I feel intrinsically uncomfortable making any value decision for the patient and avoid answering the question ‘What would you do, Doctor?’ because I am acutely aware of my own biases and heuristics. We need to create opportunities to invite, include and involve patients in our decision process. Kahneman, a Nobel prize laureate, describes this rather well!

Trainee

A BOTA survey revealed that the one thing trainees would like most from their trainers is to be treated as colleagues. I recall one of my trainers who said that his role was to sit on the buckboard while I steered the wagon and his duty was to take the reins should there be difficulty. This metaphor is profound. We should be inviting, involving and including all our trainees in everyday activities and sharing our decisions and thought processes with them. Much of what we do is nuanced and lacking in evidence. Indeed, Daniel Kahneman notes that much of clinical decision-making is experiential, rules of thumb and exchanging stories in the corridors. This is the difference between knowing the science and practicing the art of medicine. This is not learned in a book and can only be gleaned by sharing and a willingness on the part of a trainer to be fallible. A trainee can learn from experience, but a trainer can also learn from trainee. The trainee offers the willing trainer fresh perspectives and insights. Are we as trainers open to those insights and are, we willing to be challenged? I recall a trainee assisting me at the operating table chastising me in no uncertain terms for using bone wax on the sternal edges. I had applied it ‘because I have always done it that way.’ I had never taken a moment to challenge that orthodoxy. After the operation, we looked at the evidence to ascertain what interventions could reduce wound infection and implemented a tissue care bundle. Thanks to that trainee’s challenge, we have seen a fall in all sternotomy wound problems since 2009. It now sits at a median of zero on our runs chart.

We need to open ourselves to challenge, feedback and criticism and we need to invite, include and involve our patients or trainees in our clinical practice. Otherwise we risk missing valuable opportunities to learn and develop. The trainee and the patient are best placed to exorcise the doctrine ‘because that is the way I have always done it’.

About the author:

David O'Regan is the Director of the Faculty of Surgical Trainers. He has been a Consultant adult Cardiac Surgeon in Leeds since 2001.