2014 MAVLT Symposium – Innovative Learning and Teaching: The Why and The How

Uni_logo

The Melbourne Academy of Veterinary Learning and Teaching (MAVLT) formed in 2013 as a group of teaching academics within the Faculty of Veterinary Science at the University of Melbourne who wanted to share their passion and knowledge of veterinary education. The Academy hosted their first learning and teaching symposium on December 3rd and 4th 2014. The event was a great success with over 100 attendees, many from interstate and overseas. The vibe was brilliant throughout, with the engagement and collegiality palpable both in the formal sessions and the lovely reception area and garden used for breaks.

The program is available from the MAVLT website. Presentations were largely in three major themes: assessment, curriculum structure and approaches to teaching, although several talks fell outside these categories. As it is impractical for me to cover the entire event, I have chosen to review four presentations I found particularly thought-provoking. If you would like further details from any session please leave a comment to that effect.

1. Dr Liz Norman (Massey University) – Making space for innovation in veterinary teaching

Many innovative teaching ideas have recently been integrated in veterinary curricula. While there is no doubt that these have improved student learning and engagement, Liz posed a very important and oft-overlooked question – how do we decide what to leave out to balance our inclusions in order to prevent student overload?

What happens when students are overloaded?

Failure to maintain this balance leads to student overload which results in interrelated undesirable outcomes such as:

  • Superficial learning
  • Failure to make adequate connections between related parts of the curriculum
  • Inability to differentiate relevant and irrelevant material

What factors contribute to workload?

Liz then made us think about what factors make up workload. Some aspects are obvious, for example class time and independent study. Less obvious are factors such as:

  • Average reading speed, particularly taking into account the extra challenge this can be for students with English as an additional language
  • Extra time taken for group work, for example time for negotiation of work distribution
  • Preparation and organisation time, for example downloading notes from the LMS

Perception of overload

This may be very different for students and staff

Liz identified factors which influence perception of workload and ways we can decrease the perception without changing the actual amount of work. These include:

  • Aligning assessment practices with learning activities
  • Spacing deadlines across subjects
  • Setting clear guidelines for tasks and allowing time for questions
  • Increasing peer-peer and student-staff interaction

Key message

When designing innovations, be mindful of the effect they have on student perceptions of workload. Allow them the space in the curriculum they need to achieve their full benefit.

 2. Dr Chi Baik (University of Melbourne) – Is there a role for the lecture in professional degrees?

Chi’s opening comment was that she had given different versions of this presentation many times and that we may not be pleased with what she was about to say.

Debating the benefit of lectures
There are many arguments both for and against inclusion of lectures in educational programs. One factor in favour I hadn’t heard before but which struck a chord was that lectures exploit the evolutionary strengths of learning by hearing material in a social situation, the main method of learning for our hunter-gatherer ancestors. Others were more familiar, such as the opinion of supporters that there are advantages of learning from personal experiences of the lecturer and the concern from naysayers that lack of engagement with lectures tends to result in surface approaches to learning.

Benefit of lectures depends on quality

Chi’s argument was that although lectures by themselves are insufficient to provide required knowledge and skills, a good quality lecture can be a key component of a professional education program, facilitating understanding of complex concepts and modelling effective thinking.
Contrary to her expectation, many in the audience were relieved to hear support for the lecture. Chi’s challenge was for us to deliver lectures which lead to active student engagement. Ways to improve quality include learning to adapt the teaching approach to the audience and peer review.

Key message

High quality lectures are an important component of a professional education.
3. Dr Cathy Beck (University of Melbourne) – Visual arts in health education

Radiographic interpretation requires a mixture of perception (recognising a finding) and cognitive skill (interpreting the finding and recognising the implications). Study of the visual arts to improve visual observation is widely employed in medical education programs, including the University of Melbourne’s Visual Arts in Health Education Program, but has not previously been included in veterinary education.

Pilot study investigating potential benefits of including visual arts into veterinary education
Cathy teamed up with Dr Heather Gaunt from the Ian Potter Museum to conduct a pilot study to investigate the adaptation of the existing Visual Arts in Health Education Program to third year DVM students to improve visual observation skills and confidence in radiographic interpretation. The vast majority of DVM3 students who volunteered to be involved with the study reported increased confidence in the ability to interpret radiographs after participating in the pilot seminar session.

Experiencing a visual arts education
durer
After reconvening at the Ian Potter Museum and being plied with drinks and nibbles, we had the opportunity to become students in a visual arts class. Dr Heather Gaunt walked us through observation and interpretation of the multiple aspects of two large murals depicting different stages of Australian history.  Each table then had a photograph of a painting, such as one above by Albrecht Dürer, with at least one animal in it, which we studied and reported on to the group. It was fabulous to have this rare chance to dabble in the visual arts and very interesting to see the variation in perception and interpretation across the group. It gave me an appreciation of how this type of training could enhance diagnostic imaging skills.

Key message

Exposure to a well-designed visual arts education program has the potential to benefit patients through improved interpretation of diagnostic imaging studies.
4. Dr Liz Norman (Massey University) – The concept of veterinary competence: Perspectives and challenges

What constitutes competence?
While development of competence is clearly a key outcome of a veterinary education, reaching agreement on exactly what constitutes competence is surprisingly difficult. Ability to perform required technical skills is clearly part of competence but other attributes such as teamwork skills and respect for other are less obvious elements. Achieving consensus on essential elements still leaves the thorny issue of how to objectively assess competence.

Behavioural aspects of competence
Liz pointed out that competence is at least partly behavioural. Similar behaviours can be perceived as positive or negative by different assessing clinicians in different contexts. For example there may be different expectations of empathy in the small animal setting compared with food animal practice. Additional complications include:

Whether the complex interplay of factors making up competence can be assessed in parts, as is commonly done in the name of improving objectivity, or should be viewed in a holistic manner.

Whether assessment in some circumstances should be of a team or an individual as either can be competent or incompetent within the other e.g. a team may complete a task competently without all members performing to the required standard.

Is competence part of identity?
Another new concept for me from Liz’s talk was that of competency as identity. Is competency how we behave or is it more intrinsic than that? If it is, should we talk about competency in terms of being rather than or as well as doing? If the being aspect is important, we need to be particularly mindful of the way we socialise students into the profession throughout their training, a facet often developed through the hidden curriculum rather than overt teaching.

This was a very wide-ranging discussion which clearly set the audience thinking about the complexities of the topic. I’m sure many more discussions will follow.

Key message

Competency and its assessment is a complex topic and will continue to evolve as we learn more about it.

Symposium to become a biannual event

It was great to learn that the symposium will be a biannual event, with the next to be held in the first week of December 2016. Next year there will be a Ruminant Teaching Workshop held at the University of Melbourne in early December.

Posted in Uncategorized | Leave a comment

Veterinary nursing education steps up in Victoria

vet_nursing_image

All vets know the incalculable value of well trained nurses. They are multi-skilled, handing you the ideal piece of equipment just as you decide you need it one minute and putting concerned clients at their ease the next.

Current veterinary nursing education options
While vets have long been required to have a minimum of a Bachelor degree and many continue to further study, the vast majority of veterinary nurses studying in Victoria achieve the national qualification of Certificate IV, with a small percentage continuing their education to Diploma level, the highest level available to them. Anecdotal evidence suggests that many practices in Victoria
have been seeking to employ more highly qualified nurses from elsewhere, including from the UK, where 15 institutions offer higher degrees in vet nursing. The University of Queensland and Massey University currently offer the only higher degrees in Veterinary Nursing available in Australasia.
A new Associate Degree in Veterinary Nursing
That’s about to change. From 2015 a two-year full-time Associate Degree in Veterinary Nursing will be available at Melbourne Polytechnic (formerly NMIT). The Associate Degree, designed by Dr Meg Dietze after widespread industry consultation, will give students a broader education than that available through the Certificate IV, including topics such as human and facility management and evidence-based practice. Experienced veterinary nurses are offered an articulation pathway into the Associate Degree with nurses holding a General Diploma eligible for block credit for the first year of the degree.

The newly-built facilities at the Epping campus will give students a chance to develop skills in a simulated environment before undertaking clinical placement at Lort Smith Animal Hospital, where they will be exposed to a large case load and have their learning supported by vets and nurses trained as clinical coaching associates. At the end of the course they will spend six months working in a variety of veterinary industry settings, both clinical and other areas of interest. Other innovative teaching strategies to be adopted include adaptation of a human nursing system for assessing clinical skill development (outlined in this paper presented at the AVA conference in 2013) and the use of a fictional clinic as a teaching tool. The clinic has been populated with staff and clients, each with their own personality, and patients with a range of common health issues. This will facilitate teaching skills ranging from client and professional communication to case management.

Along with the new Bachelor of Veterinary Technology offered by Charles Sturt University, it is fantastic to see the options for professional development for veterinary nurses expanding so rapidly. Having been involved in writing of some of the first year teaching materials for the Associate Degree at Melbourne Polytechnic, it’s wonderful to see all the hard work put into the development come to fruition. I know this course will give its students a fantastic beginning to their veterinary nursing career and I am sure they will go on to become valuable members of the profession.

Posted in Uncategorized | Leave a comment

‘Has Rex improved?’

The caregiver placebo effect in veterinary medicine

Bad_Science

After a long break from blogging on professional topics (although not from blogging in general – if you would like access to the blog from our fantastic trip around the western part of Australia please leave a comment to that effect) I have returned to work and am reading Ben Goldacre’s Bad Science, an eye-opening look at the sometimes questionable studies on which current treatments and accepted wisdom may be based. I had not previously heard of Goldacre, a UK-based doctor, epidemiologist, broadcaster and author who has an incisive mind and a lovely turn of phrase, my current favourite of which is ‘The plural of anecdotes is not data.’ As a bonus in discovery of interesting thinkers, researching this post also lead me to discover The SkeptVet blog, written by a blogger who ‘takes a sceptical and science-based look at veterinary medicine.’

One of the many topics covered in Bad Science is the placebo effect. As a student my somewhat primitive understanding of this concept was that placebos were substances which had no effect in treating a condition and were most often used in clinical trials to provide a control with which to compare the medication being investigated. I assumed that the placebo effect, where beneficial effects of the substance were thought to be due to the patient’s belief in the treatment rather than the treatment itself, was not a significant issue in veterinary practice because placebos didn’t have the same psychological effect in animals as in people. Once graduated, I encountered some vets who occasionally gave sterile water or vitamin injections to patients to satisfy owner demands. This was my first experience with the caregiver placebo effect, also known as the placebo effect by proxy, of which more later.

Surprising researching findings 

Goldacre reports on several studies which investigated the placebo effect, some of which had some very revealing results. Placebo tablets have been found to have a dose-response curve in the way you would expect for other drugs (two tablets were perceived to be more effective than one), to be influenced by the colour of tablets (pink tablets helped maintain concentration better than blue tablets) and to be being more effective when injected than when taken in tablet form. In a more extreme form of placebo, patients with pacemakers implanted but not switched on reported feeling better than before having the device implanted (although they did better still after the device was activated!)

Fascinatingly, the doctor’s faith in a particular treatment can also have a significant effect on the outcome for a patient. In a creative study in the mid-1980s, two groups of doctors who were blinded to which medication they were injecting, gave one of three possible treatments to patients. Of the three, only one was effective for the patients’ condition. One group was told that the treatments they were giving were ineffective and the other group were told the truth – that there was a chance their treatment could benefit the patient. Doctors were forbidden to tell patients the chance of their treatment being effective. No prizes for guessing that the patients of the second group did better. Apparently the manner of the doctor was enough to influence the outcome for the patient.

 The caregiver placebo effect has significant influence

In veterinary medicine, the vet obviously communicates about the likely success of treatment with the caregiver rather than directly with the patient. The vet’s and owner’s opinion on whether the patient has improved are significant in the vet’s assessment of the success or otherwise of treatment both in day-to-day patient management and in clinical trials. The SkeptVet blog led me to a study1 which attempted to assess the impact of the caregiver placebo effect on outcomes for dogs with lameness due to arthritis. Using animals assigned to the placebo arm of a clinical trial, owner and veterinarian assessments of dog’s response to treatment (placebo) were compared with objective measurements of weight bearing in affected limbs. A placebo effect was noted in over 55% of owner assessments and over 40% of veterinarian assessments.

In an ingenious attempt to elicit the impact of the caregiver placebo effect, a separate study2 on the effects of a non-steroidal anti-inflammatory treatment (meloxicam) on cats with degenerative joint disease (DJD) divided patients into two groups. One group received meloxicam, well-established as a treatment DJD in cats, for three weeks and then placebo for a further three weeks whilst the second group received only placebo throughout the trial. Owners did not know which group their cat was in. Cats were assessed by owner surveys prior to the study, after three weeks i.e. at the time of cessation of meloxicam for those receiving it and finally after six weeks. At the midpoint of the study, cats from both groups were perceived to have improved to an extent not significantly different between the two groups. At the end of the trial, cats in the meloxicam treatment group were perceived to have deteriorated compared with their midpoint assessment while those in the placebo group remained unchanged. The authors propose that the positive effect of the meloxicam in the first three weeks of the trial was masked by the caregiver placebo effect but once the meloxicam was replaced by the placebo, the return of clinical signs after withdrawal of active medication negated this effect.

Such studies illustrate the importance of the caregiver placebo effect in veterinary medicine, both for their veterinarian assessment of the patient and those of the patient’s owners. As veterinary educators, we should ensure that our students are forewarned of the phenomenon and remind mindful of it while working in clinical practice.

References

1 Conzemius M, Evans R. Caregiver placebo effect for dogs with lameness from osterarthritis. J Am Vet Med Assoc 2012;241:1314–1319

2 Gruen ME, Griffith E, Thomson A et al. Detection of Clinically Relevant Pain Relief in Cats withDegenerative Joint Disease Associated Pain. J Vet Intern Med 2014;28:346–350

Posted in Uncategorized | Tagged , , , , | Leave a comment

Education Day at AVA 2014 part 2

 

confeence_logo

This is the second blog post covering Education Day at the 2014 AVA Conference in Perth. The first post covered sessions relating to teaching and learning communication skills, both for students and for professional development of educators. This final post covers the remaining 3 presentations and the poster session.

Developing online resources for clinical teachers

In his talk entitled ‘Developing online resources for clinical teachers’ Daniel Schull explained why (the difficulty of providing face-to-face training made online the best option) and how the University of Queensland is developing an online self-directed induction resource for clinicians and staff instructing students on the clinic floor. After researching similar products used in other healthcare settings and completing a user survey to determine relevant content areas, content is being developed in developed as a series of progress-tracked bite-sized modules. The main aims of the resource are to raise participant awareness of their important teaching role, highlight useful  background theories, offer practical tips to assist with the role, and provide a flexible delivery format to suit the busy and unpredictable nature of clinical work. The resource is currently being piloted by  a  user group  comprised of  content experts from a range  of medical, veterinary and veterinary nursing backgrounds, and veterinarians and veterinary nurses from university and external clinical practices. Feedback from this user group will be secured via an online survey and semi-structured interviews. Post-launch evaluations will include a range of metrics such as user completion rates and feedback.

Clinical Problem Solving Exams

Digital resources in the form of clinical scenarios are also being used at Murdoch University in their Clinical Problem Solving Exams. This form of assessment was introduced in 2010 to try to improve the observational, critical thinking, communication, analytical, intervention and re-evaluation skills of students. The majority of questions are short answer questions (SAQ) with some multiple choice questions (MCQ) and some extended matching set questions (EMSQ). Progressive disclosure is a key component of the exams as it is more authentic to clinical practice and allows students to be redirected if they make an error early in a question. Unsurprisingly students initially find this component particularly challenging as it prevents them from taking an information dumping approach to answering the questions. With more clinical exposure and clinical experience students appear to realise the validity of the CPSE style of examination with progressive disclosure.

In contrast to other presentations, Sandra de Cat from James Cook University focused on ‘sheep week’, a week half way through the course dedicated to small ruminants. Students and staff travel several hundred kilometres to visit sheep properties who have taken different approaches to the industry. Hands on learning is integrated with previous knowledge to help the students ‘bring it all together.’ With its highly integrated curriculum, this style of learning is a good fit at JCU and very popular with the students, some of whom are struggling with the dip in motivation which often occurs midway through the course. Requests for dedicated ‘weeks’ for other species have been a common feature in student feedback, an indicator of the value students feel they get from the week.

 Poster presentations

An excellent poster session was held during the afternoon. In contrast to previous years, a three minute presentation in the meeting room was allocated to each poster rather than having posters presented with the audience standing around the posters, which was certainly more comfortable. For each poster, only the author who presented the poster has been named. If you are interested in learning more about any poster, please leave a comment and I will send more information. Posters presented were (in no particular order):

Adele Feakes (University of Adelaide) – Re-shaping veterinary business curricula to improve graduate business skills: a shared resource for educators

Adele Feakes (University of Adelaide) – Career sector intentions and gender effect: a cross-sectional analysis across year levels in four Australian veterinary programs in 2012

Chris Riley (Massey University) – How effective is ‘Best Practice’ training in the prevention of horse-related injuries to students?

Elise Boller (University of Melbourne) – Developing a framework for teaching professional communication skills in the University of Melbourne

Eva King (University of Queensland) – Learning from the learners: final year veterinary students’ perceptions of what helps and what hinders their learning in clinical environments

John Inns (University of Melbourne)  – Application of the proprietary, web based, curriculum mapping program Rubicon Atlas to map the Melbourne DVM curriculum

Liz Norman (Massey University) – Best practice in writing MCQs: why three options is enough

Liz Norman (Massey University) – Best practice in assessment: Using the SOLO taxonomy

Stuart Barber (University of Melbourne) – Collaborative development of virtual 4D farm systems for veterinary education

Susan Matthew  (University of Sydney) – Evaluation of the effectiveness of models in teaching surgical skills

 

 

Posted in Uncategorized | Leave a comment

Education day at AVA 2014

confeence_logo

 

 

Tuesday May 27th was education day at the 2014 AVA Conference.  As in previous years, the program consisted of papers, posters, a dinner and lots of excellent networking opportunities. After being on the road for 3 months around the western half of Australia (if you would like to read our trip blog please leave a comment to that effect and I’ll invite you), arriving at the conference was akin to landing on another planet and it took me a while to feel I could hold a professional conversation, much less give a coherent presentation but happily I had reassimilated within a few hours and was able to get the best out of my experience.

Although there was quite a variety of topics, a particular theme was teaching non-technical skills, particularly communication, in veterinary curricula. This first post will cover presentations which related directly to communication both in relation to teaching and professional development.

Non-technical skills in the veterinary curriculum

Martin Cake’s presentation ‘Consensus and evidence for the importance of non-technical veterinary skills’ gave a thought-provoking overview of what non-technical skills are perceived to be important by students and veterinarians and which skills have actually been shown through evidence to influence the success of veterinary graduates. Using the BEME (Best Evidence Medical Education) framework, meta-analysis of the literature showed evidence that 4 non-technical skills are of particular importance. The four are:

  • client trust/respect,
  • awareness of limitations,
  • communication skills
  • critical thinking/problem solving.

When consensus on perceived importance is matched with evidence of importance, communication skills lead the field, validating the strong focus this area of training has received in veterinary curricula.

Teaching clinical communication skills

Two presentations described the ways in which different vet schools instill clinical communication skills in their students. Jenny Mills and Melinda Bell described different techniques used at Murdoch, which include video scenarios, skills rehearsals of challenging situations such as euthanasia consultations and client simulations used at different stages in the curriculum. Particular focuses in that school are clinical empathy and inter cultural competence. Assessment includes several reflective tasks, such as a reflecting on video scenarios in the ‘Talk to the humans’ videos developed at Murdoch, immediate informal feedback after simulation exercises and videoing themselves in consultations and using the recording to review and self-assess their skills. OSCEs in final year form the ultimate summative assessment. Challenges at Murdoch are seen as including to provide more opportunities for students to record their consultations, to find more time for communication training in a crowded curriculum and to extend scenarios to include large animal cases.

Susan Matthew from Sydney University described some similar challenges in teaching clinical communication skills with time and resources but also spoke about the additional concern of the attitudes that some students bring to the discipline. Perceptions including lack of relevance in comparison to core scientific subjects and the belief that communication skills have already been acquired and can’t be developed further can hinder the teaching and learning process. The requirement for active participation e.g. in role play scenarios is challenging for many students, particularly the more introverted, and some take feedback on their performance as a personal affront. These student concerns lead to poor evaluations of those sections of the curriculum.

Communication through social media 

Jason Coe from Ontario Veterinary College spoke about communication training of a different type, focusing on educating students on the benefits and risks of social media, particularly Facebook. Studies have shown that veterinary students have a high rate of disclosing personal information and of posting material classed as unprofessional on Facebook. Using clickers to gauge audience opinion, Jason took us through a series of Facebook posts and asked whether we thought the various posts were acceptable and in some cases compared our response to those of vets and vet students they had surveyed in Canada using the same scenarios. While some items were clearly not acceptable to the group, others produced a wider range of opinions.

In his curriculum for veterinary students, making students aware of the potential consequences of their actions using real case is an important facet, as is introducing them to the 4 principles of ethical decision making in veterinary practice – non-maleficence, beneficence, autonomy, and justice.

Twitter for teaching and professional development

Continuing the topic of social media but broadening to include opportunities for professional development as well as teaching, I presented on the use of Twitter for veterinary educators, highlighting the features that make Twitter a useful tool for teaching and professional development and showing 3 examples of how it is currently being used for disseminating ideas or research, for teaching using #vetfinals as an example and for creating a conference back channel.

A second post will cover the remaining presentations and the excellent poster session.

 

Posted in Uncategorized | Tagged | 3 Comments

I’ve made mistakes in veterinary practice. Have you?

The ‘second victims’ of clinical error

Brian_Goldman

In my first year in practice, I worked in a very busy clinic which also acted as an emergency centre after hours, at the time one of three large emergency clinics in Melbourne. Among the enormous number of cases, I made some great clinical decisions but also some howling errors. Two immediately spring to mind. The first was a white kitten bleeding from around a tooth which I attributed to the fact that it was losing its deciduous teeth, but was due to eating Ratsac (a Vitamin K antagonist), a realisation which hit me about an hour later. I rang the owners, who brought the kitten back and it recovered with treatment. The second was a cat brought in unable to move its hind limbs. I initially assumed it had been hit by a car but it had a saddle thrombus secondary to cardiomyopathy. I remember noticing during the consult in some distant corner of my mind that its hind paws were cold but it wasn’t until I was positioning it for a pelvic radiograph that my neurones connected the cold paws and paralysis and I proceeded to work it up and treat it for thromboembolism and cardiomyopathy.  The fact that I still cringe at my clinical blindness and recall minute details of both cases 15 years later illustrates the impact they had on my psyche. I was ‘the second victim of the error’, a phrase coined by Professor Albert Wu1 to describe the impact of errors on clinicians, nurses and other support staff.

I have previously written about cognitive aspects of diagnostic error. Brian Goldman’s TED talk, ‘Doctors Make Mistakes. Can we talk about that?’2 (thanks to Jan Ehlers for the link) discusses errors from a clinician’s perspective and reminded me that my fear of errors contributed to my decision to move away from practice. I have only ever admitted that to others who I know share my anxiety because in some way I am still ashamed. I will never make those mistakes again.

After listing some of his own errors, Goldman, an emergency physician well-known medical journalist in Canada, talks about striving to be a perfect and resisting asking for help for fear of being seen as high maintenance. In the aftermath of an error, he recounts thinking, ‘make the voices (in his head) stop and don’t let me make another mistake’. I related completely.

Goldman feels that the culture of silence around error is a major contributor to the feelings of shame and isolation a clinician may feel after making a mistake. Albert Wu agrees, stating that ‘confession is discouraged, passively by the lack of appropriate forums for discussion and sometimes actively by risk managers’.1  This culture has been attributed to the ‘hidden curriculum’ in medical education – the messages and attitudes transmitted through day-to-day attitudes, actions and vocabularies.3

Failure to support the emotional needs of clinicians after an error can have significant consequences such as poorer patient care, depression, burn out, premature retirement4 or, in particularly tragic cases, even suicide5. Wu notes that …’some of our most reflective and sensitive colleagues [are] perhaps most susceptible to injury from their own mistakes’1, a category I feel I fit into.

At a personal level, strategies to support colleagues after errors may include encouraging a description of what happened, affirm rather than minimise the importance of the mistake and disclosing your own mistakes to help reduce the sense of isolation. Acknowledge the emotional impact of the mistake and ask how the colleague is feeling.1 At a broader level, Goldman suggests better systems to reduce errors and rewards for identifying errors and for coming forward after an error has occurred.2

In my experience, a similar culture of silence around clinical error exists in veterinary practice. I shared my mistakes with close friends, who were extremely supportive and, as new grads, also had their own stories. Systems for coping with errors were never mentioned during my veterinary education. There is now rightly a far greater focus on mental health of veterinarians and much better support, for example through the Australian Veterinary Association, although I could find no mention of clinical error in their VetHealth section. I would be very interested to hear of any specific veterinary examples of support for veterinarians or veterinary nurses after an error has occurred or systems to help us learn from errors.

Where there are clinicians and medical and veterinary support staff there will always be errors. The second victim is also important.

References

  1. Wu AW. Medical Error: the second victim. BMJ. 2000; 320(7237): 726–727.
  2. TED. Doctors Make Mistakes Can We Talk About That? http://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that.html. 2012. Retrieved 8 February 2014.
  3. Liao  JM, Thomas EJ, Bell SK. Speaking up about the dangers of the hidden curriculum. Health Aff 2014; 33(1):168-171
  4. Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser V, Gallagher TH. The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada. Joint Comm J Qual Patient Saf 2007; 33(8):467-76
  5. NBC News. Nurse’s Suicide Highlights Twin Tragedies of Medical Errors http://www.nbcnews.com/id/43529641/ns/health-health_care/t/nurses-suicide-highlights-twin-tragedies-medical-errors/#.UviuNfmSySo. 2011. Retrieved 10 February 2014.

 

Posted in Uncategorized | 4 Comments

Diagnostic biases

 

how-doctors-think_cover_imageIn a previous post I discussed the widespread, and, in my case, unwitting, use of heuristics in clinical decision making. The advantages of heuristics, such as managing complexity and improving efficiency are well documented but equally they can be a disadvantage by leading to faulty reasoning and conclusions1.  One disadvantage is that they can contribute to cognitive bias in clinical decision making. Cognitive bias is defined as a pattern of deviation in judgment, whereby inferences of other people and situations may be drawn in an illogical fashion2. Several important cognitive biases deriving from heuristics are discussed in Jerome Groopman’s book ‘How Doctors Think’3. Some of the more common are:

The availability bias – ‘the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind.’3 (p.64) An example could be that having seen several cases of kennel cough recently, a cough due to heart disease may be misdiagnosed as the veterinarian recalls quickly the current outbreak of kennel cough.

The anchoring bias – the ‘tendency to perceptually fixate on to the salient features in the patient’s initial presentation at an early point of the diagnostic process and failing to adjust initial impressions even in the light of later information’4

The confirmation bias – related to the anchoring bias, this refers to the tendency to look for confirming evidence to support the diagnosis we are “anchoring” to, while downplaying or ignoring information that might contradict the initial diagnosis.

The satisfaction of search bias – the tendency to stop looking for alternate or even coexisting diagnoses when we have made one diagnosis. A classic example of this is not searching for a second fracture once “sufficiently satisfied” with finding the first fracture5.

Many vets, particularly more recent graduates, worry that they won’t have sufficient knowledge of clinical disease but in fact the vast bulk of diagnostic errors come from cognitive mistakes6. Reflection on the clinical evidence available is a recommended way of limiting errors due to faulty clinical reseasoning7. Core questions include:

  • Why do I favour this diagnosis?
  • What else could it be?
  • Could two things be going on?
  • Have I considered the finding or lab result that doesn’t quite fit?7

Awareness of these potential errors is a great step towards reducing the chance of falling into the common traps.

Beside the scientific basis of clinical error, mistakes can have significant impact, obviously on the patient, but also on the clinician. Media coverage and complaints processes rightly concentrate on the former, while the failure to discuss the latter can be devastating to the people involved. As a clinician who has made mistakes, my next post will discuss the culture around clinical error.

1. Elstein, AS., 1999. Heuristics and Biases: Selected Errors in Clinical Reasoning. Academic medicine, 74 (7), 791-4

2. Cognitive bias – Wikipedia, the free encyclopedia. 2013. Cognitive bias – Wikipedia, the free encyclopedia. Available at: http://en.wikipedia.org/wiki/Cognitive_bias. [Accessed February 10, 2014].

3. Groopman, J., 2007. How Doctors Think. Houghton Mifflin, Boston

4. Emergency Medicine Blog: Heuristics and Cognitive Biases in Decision Making During Clinical Emergencies. 2013. Emergency Medicine Blog: Heuristics and Cognitive Biases in Decision Making During Clinical Emergencies. Available at: http://emergencymedic.blogspot.com.au/2012/01/heuristics-and-cognitive-biases-in.html [Accessed 30 August 2013].

5. Croskerry, P., 2009. A Universal Model of Diagnostic Reasoning. Academic Medicine, 84(8), pp.1022–1028.

6. Croskerry, P., 2003. Cognitive Forcing Strategies in Clinical Decision making. Annals of Emergency Medicine, 41(1), pp.110–120. Available at: http://home.comcast.net/~jasoncillo/Cognitive.pdf [Accessed February 10, 2014].

7. Misbah Keen University of Washington School of Medicine, 2013. Medical Decision Making in Clinical Care: Avoiding Common Errors. Available at: http://healthinfo.montana.edu/WWAMI Conference/Medical Decision Making 2013-04.pdf [Accessed February 10, 2014].

Posted in Uncategorized | 1 Comment