2011; 33: 578–579
The story of health care’s Achilles’ heel FEDDE SCHEELE VU University Medical Centre, The Netherlands
Abstract Medical education for future practice is addressed with the use of a narrative from the obstetric field. Medical expertise is present within the health care teams described. Due to inappropriate use of hierarchy and insufficient team work knowledge is not effectively being shared. A plea is made for a reappraisal of generic competencies in medical education and training.
Introduction The story you are about to read may be considered to be a narrative (Fisher 1987). This narrative contains a comprehensible message that is important for medical education. Medical education has to develop toward a situation in which the student or trainee is prepared for two areas of focus. The first focus is the traditional one and will address medical expertise. The second focus has to address issues like contextual awareness and team work. To accomplish this, second focus is an important but very difficult task as will be illustrated in the presented narrative.
Method Since the end of the previous century, the narrative has been increasingly recognized as a way to remember and communicate important ideas and values. The narratives you believe in are building bricks for your common behavior. They connect you with people that cherish the same narratives. While collecting important narratives, you develop as a person and as a professional. Recounting narratives, I have found a large number of people who identify themselves and their experiences in these stories. To avoid individuals being identifiable within these narratives some changes have been made, however the basic underlying experiences remain unaltered.
Results This narrative is about a doctors’ and nurses’ dilemma. In the setting of our delivery ward in a general hospital, the first delivery of Mrs White was about to happen. It was 4.30 am and young doctor Andrew was working with an experienced obstetric nurse, Julia. Andrew had 1 year experience as a house officer. Julia had been working in the area of obstetrics for over 25 years. She had seen it all, but she was still a mild and friendly person.
Practice points . Health care teams may not effectively share the knowledge of their members. . Contemporary health care problems demand more educational focus on generic competencies.
Andrew had been evaluating the cervical dilatation. The delivery was going to last for at least a few more hours. The monitoring of the baby’s heart frequency showed signs of mild distress. A blood sample of the fetal scalp was being analyzed in the laboratory. At 5.05 pm, Andrew discussed by telephone the delivery data with the consultant on call. They decided the distress was not serious enough to choose for a cesarean section. It would be appropriate to repeat the scalp sample about 1 h later. Because of a relative stagnation of the progress of cervical dilatation, Andrew decided to augment labor with the hormone oxytocin. Oxytocin is used to increase the frequency and the strength of the uterine contractions. Julia did speak up to her house officer. She told him the combination of mild fetal distress and augmentation of labor might introduce serious risk for the unborn baby. Andrew explained that he wanted to speed up the process because a prolonged course of delivery would also be dangerous in this case. Julia was worried, but was overruled by the atmosphere of hierarchy. This young house officer had been to medical school and had already some experience. Formally, he was in charge and was allowed to take responsibility. When at 5.30 am, the fetal cardiac monitor had been showing more severe signs of fetal distress, Julia asked whether the next fetal blood sample could be done immediately. Andrew decided to wait for half an hour. When at 6.30 am the result came in, there was evidence of serious fetal distress. An emergency cesarean section has subsequently been performed, but unfortunately the child did not survive the asphyxia. All nursing and medical staff involved met the next day to reflect on the event. Julia felt she should have spoken up more rigorously. Andrew had learned the risk of oxytocin and felt
Correspondence: F. Scheele, St Lucas Andreas Hospital, Jan Tooropstraat 164, 1061AE Amsterdam, The Netherlands. Tel: 31-615640929; fax: 31-206853879; email:
[email protected]
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ISSN 0142–159X print/ISSN 1466–187X online/11/070578–2 ß 2011 Informa UK Ltd. DOI: 10.3109/0142159X.2011.578175
Plea for generic competences
depressed that he did not make the right decisions, despite the fact that Julia had been trying to help him. The consultant felt he should have come in to assist the relatively inexperienced house officer in a more complex case. Of course, much more was discussed and several emotions were shared. For most of those involved it was clear the system had failed. A few weeks later, the nursing and medical staff decided to introduce new rules to make a nurse more effective when speaking up. If a discussion about the treatment of a patient would remain unsolved, nurses were invited to call in the consultant themselves. At least a third party should be involved in complex discussions about a patients’ case. It was only a month later that I was on duty myself. I was proud to be the hospital’s leader in a ‘‘Speak up’’ project, to empower personnel to share their views on good patient care and to decrease inappropriate use of hierarchy. We had organized several communications on this subject and even gadgets were used to support this new narrative that would be shared by the workers of our hospital. We were going to speak up! No more debilitating hierarchy! Life seems to be so easy and beautiful. After a night of hard work, my mind usually reacts to exhaustion with feelings of happiness and invincibility. Therefore, after such a night, I should make sure to stay in my bed. However, this specific day, the team was attacked by flu and I was asked to go on supervising the delivery rooms. I was happy to help out the team. Time went on without real mistakes, until this case with a retained placenta came in. The senior house officer and the midwife could not get the problem solved and asked me in. I had to judge whether my manual skills would suffice. If that would not be the case, because of the risk of serious hemorrhage, we should prepare the woman for an emergency procedure at the operation theatre. It demands a skill that develops during many years and I enjoyed getting the placenta out in the delivery room. The placenta was a small one and you can probably imagine me happily saying ‘‘that is a small one for such a beautiful baby.’’ That’s what happened. Not one of my personnel spoke up. No one suggested looking with ultrasound for the other half of this ‘‘placenta bipartita.’’ One and a half hours later, the massive blood loss started. A procedure on the operation theatre combined with the emergency infusion of fluid, blood and coagulant substances saved the woman. I felt that I failed. I had not judged this case well. Worst of all, I judged the case of the ‘‘speak up’’ as an easy one too!
Discussion When expecting nurses and midwifes to speak up, we have to work at a change of culture. That is not at all easy. We are looking for a balance between hierarchy and the use of the immense source of knowledge and skills coming from all team members. New ways of collaboration of teams have to be chosen carefully. From all over the world, several expert groups have created frameworks for future medical education, e.g., Tomorrows Doctors from the UK (GMC 2003). After translation to the medical curricula, the new skills need years of training (Frank & Danoff 2007). Multi-professional education could be helpful in this process (Oandasan & Reeves 2005). Patient participation in the construction and exertion of
curricula could also be of major importance, but often seems to be a bridge to far. Inclusion of the patient in the health care team could be a logic step in the change from a doctor centered (with a rather selective focus on medical expertise) to a patient centered health care system (Florin & Dixon 2004) (with more focus on context and team performance). The introduction of generic competencies, as well as methods like multi-professional education and patient participation (Fudge et al. 2008), should be subject to research and evaluation. The medical school I am working for is innovative and reflective. However, there is still no research department that does studies on collaborative and organizational issues in health care with immediate impact on medical training. This is different from our research on cell biology which is indeed effectively communicated to the students. In both cases described in the narrative, medical expertise was not the biggest issue. In most disasters in the clinic, communication, collaboration (including patient participation), organization and professionalism are the most important issues. These issues are today’s Achilles’ heel of medical health care and medical personnel reports training deficiencies (Westerman et al. 2010). For future medical education, we should focus on evidence based and well-designed training programs for these generic competencies. Traditionally, medical personnel are trained to focus on technical expertise. For the future contextual awareness and team skills are mandatory!
Acknowledgment This study was conducted in the VU University Medical Centre, Amsterdam, NL. Declaration of interest: There is no declaration of interest to report.
Notes on contributor FEDDE SCHEELE, MD, PhD, is assigned at the VU Medical Centre, Amsterdam, The Netherlands, to improve medical education and clinical training.
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