A Yellow Wood by Gill Stanyard

The 1st June 2018 was my  last day as a  Non-Executive Director for NHS Dumfries and Galloway.  After four years of a potential eight year appointment from Scottish Government, I decided to  leave. I felt I had reached a good and fulfilling end and to stay on for another four year term would have been signing up to endure.  I made a decision I wanted to enjoy. So, I felt happy with my decision to end my time, made when swimming in a shimmering blue sea one early morning, whilst in Greece.

I made a decision. ‘Decision.’ The Latin origin of this word  literally means, “to cut off.” Making a decision is about “cutting off” choices – cutting you off from some other course of action. Now that may sound a little severe and limiting, it’s not. It is liberating. Decisions, they take us onto the next stepping stone, sometimes called  ‘The End’  – two words which tell us a story is over.

My friend made the final and shocking decision to end his life at the weekend. A fact I am still struggling to comprehend. Our last communication was a fortnight ago, with me texting him about all the different gins (24 to be exact) that were on the menu at my leaving ‘do.’  He texted me back with a  joke about Rhubarb gin. Then nothing. I didn’t think too much of it, life gets in the way. And then I received ‘The News.’  Yet I have forgotten a couple of times since then, and have gone to text him. Then, with a strange physical ‘flipflop’ stomach feeling,  I have remembered ‘The End,’ which is accompanied by much hurt and sorrow and  strangely, lines from one of my favourite poem’s. – ‘ The Road Not Taken.’ by Robert Frost:

Two roads diverged in a yellow wood,

And sorry I could not travel both

And be one traveler, long I stood

And looked down one as far as I could

To where it bent in the undergrowth;

 

Then took the other, as just as fair,

And having perhaps the better claim,

Because it was grassy and wanted wear;

Though as for that the passing there

Had worn them really about the same,

 

And both that morning equally lay

In leaves no step had trodden black.

Oh, I kept the first for another day!

Yet knowing how way leads on to way,

I doubted if I should ever come back.

 

I shall be telling this with a sigh

Somewhere ages and ages hence:

Two roads diverged in a wood, and I—

I took the one less traveled by,

And that has made all the difference.

 A single decision can transform a life. I always assumed Frost wrote this poem about himself, yet I recently read Hollis’s  biography of Welsh poet Edward Thomas, and discovered that Frost and Thomas were ‘besties.’  Frost had written the lines as a joke about Thomas’s depression induced indecision, which showed up on their long ‘walk and talk’ days together, with Thomas never being able to decide whether to take the path on the right or the left. When Frost sent the poem to Thomas, Thomas initially failed to realize that the poem was (mockingly) about him. Instead, he believed it was a serious reflection on the need for decisive action. At the age of 36, after much wrestling, Thomas felt compelled to enlist as a soldier in the Great War.

He wrote of his decision to his friend Robert Frost  “Last week I had screwed myself up to the point of believing I should come out to America & lecture if anyone wanted me to. But I have altered my mind. I am going to enlist on Wednesday if the doctor will pass me.”  On the first day of the battle at Arras, Easter Monday, 9 April 1917, Thomas was killed by a shell blast.  His poem ‘Adlestrop’ was published in the New Statesman three weeks after his death and has since become a classical favourite of British poetry.

Adlestrop

Yes, I remember Adlestrop —

The name, because one afternoon

Of heat the express-train drew up there

Unwontedly. It was late June.

 

The steam hissed. Someone cleared his throat.

No one left and no one came

On the bare platform. What I saw

Was Adlestrop — only the name

 

And willows, willow-herb, and grass,

And meadowsweet, and haycocks dry,

No whit less still and lonely fair

Than the high cloudlets in the sky.

 

And for that minute a blackbird sang

Close by, and round him, mistier,

Farther and farther, all the birds

Of Oxfordshire and Gloucestershire

Life sometimes makes decisions for us. I don’t mean to get all Dead Poet’s Society here, yet I think T.S Eliot had something when he wrote “What we call the beginning is often the end. And to make an end is to make a beginning. The end is where we start from.” (Four Quarters) We get ill and have to take time to rest and get well, and sometimes we don’t always recover, we have accidents,  we don’t get chosen for that job or by that person and we lose people and animals we love and care for.

Where possible, make a decision and choose your ending and make a new beginning, whether it be the end of an unhappy relationship and the start of a happier one with yourself,  saying No to working for extra hours, when you could be saying Yes to spending more time with your family, or your dog or your garden, standing up to a bully and choosing to start being assertive and courageous, speaking out against something which you see is wrong and thus ending corruption or collusion, stopping trying to do everything by yourself and start asking for help -(getting a mentor through NES really helped me with this)  and putting a stop to being taken for granted and drawing new boundaries that put your needs first.

I have taken a Non-Executive decision to be more accountable to myself in my life, to spend more time outside, to stop watching tv and read more poetry,  to save up to live in a place where I can have two donkeys, chickens and  another rescue dog and to track down some Rhubarb gin.

Sorry if I did not see you to say Goodbye. I wish you well in your decision making and hope that your sigh is a happy and fulfilled one.

I

Prioritisation in NHS Scotland by Ewan Bell

I have to make it clear from the outset that the views expressed here are my own – these are my personal views.  They are nothing to do with being Associate Medical Director in NHS Dumfries and Galloway and do not reflect any local management or Board view! I’m writing this as an avid armchair follower of politics, current affairs and economics! I should also stress that I am a member of no political party.

To put my views in context, I should state that I believe that there are 2 fundamental and essential pillars of a fair society;

• Equality of opportunity; in real terms this means free access to education and zero tolerance of discrimination
• Free healthcare; people should not suffer or die because they can’t afford to pay for health-care

I am a passionate believer in the concept of the NHS and free health-care for all. My mum and dad tell me stories about how their grand-parents couldn’t afford to go to see the Doctor. In my view this is unacceptable, incompatible with a fair society and must remain in the past. 

On one hand we have increasing costs due to advances in health-care technology, changing demographics, increased expectation and the costs of prescribing. And on the other hand we have limited resources. Demand will always outstrip capacity. Just about every health-care system in the world is wrestling with this challenge, no matter whether they are publicly or privately funded. There will never be unlimited resources, or indeed adequate resources, to provide all health-care, free of charge, for all people. So how should we, as a society, respond to this challenge?

Let’s consider an analogy.  All households have a defined income. We might moan about it and complain, but there’s not much we can do about it. So how do we respond to this? Most organised households will budget and align expenditure with income. There are fixed essentials, such as tax, national insurance, council tax and rental (or mortgage) payments, over which we have little control. But there are other outgoing costs which can be varied and influenced by the household (maybe not enthusiastically), such as, for example, food, clothes, heating, alcohol, etc. If times are hard, then a household will pull back to the fixed essentials and moderate spending in other areas, or to put it another way, the household will prioritise its spending.

If we apply this approach to health-care, then we need to start debating and defining the essentials of health-care and what can we pull back from. In other words, we really are going to have to start discussing what we should be focusing our limited resources on and what we should stop doing, as not all interventions are equal.

I suppose this goes back to my initial views on the pillars of a fair society. To maintain free health-care for critical, core services in the NHS, we are going to have to start redefining what health-care means and acknowledge that we can’t continue to provide the current range of interventions and services, if we want a sustainable NHS for the future.

So, what are the essentials and what should we stop doing?

Dr Ewan Bell is a Consultant Biochemist and Associate Medical Director for NHS Dumfries and Galloway

 

 

 

 

 

 

Decisions Decisions by David Macnair

Do you make decisions at work? I’ve asked this question a lot. The reply is usually the same. A hesitant nod of the head, perhaps. Or a lop-sided shrug with that expression that says “Dunno. Do I?” Despite making decisions every minute of every day, we most often don’t notice we are doing it. Which means we can make it better. We can ask, “Do you make good decisions?”

In fact, we human beings are decision making machines. We might make life or death decisions about patient care. But it is mostly humdrum day to day decisions. When am I going to get up for work? Which buzzer am I going to answer first? Shall I go for a pee before I do the next task? Should I push or pull that door?

First let us look at how we make decisions. These four categories cover most of the ways we make decisions in a clinical setting. They are:

• Option appraisal
• Rule based
• Novel solution
• Recognition primed

Let’s take a look at each of these in some more detail.

1: an example of a poor decision

Option Appraisal

Do you recognise this heroic looking guy?

2: The Thinker

Option appraisal is the classical approach to decision making. One sits hunched with chin in hand and thinks of all of the possible options for a given situation. Each of these options is weighed up individually, looking to see the pros and cons. When finally a single best option is clear, a decision is taken. The major benefit of this approach is that it is the most likely to produce a good decision for the given situation. It is also easier to justify your decision later. Unfortunately, there are drawbacks. It requires mental effort and time. It requires a systematic approach. If you don’t know all the possible options, you could miss the right one! It requires some background knowledge. A medical example of option appraisal is writing a differential diagnosis. This is a list of possible illnesses (ie options) that a patient with particular symptoms might have. Writing a differential diagnosis forces you to consider diagnoses other than just the one you wrote first.

But is this how we usually make decisions? No! Of course not. If every decision we made required this process, we would become paralysed; unable to get anything done for thinking about it.

Rule based

3: Guidelines say we have to have 5 nurses on the ward. This is Sandra, also known as Claire, Fiona, Jade and Emma.

This one is easy. Think of a guideline, any guideline. This can be thought of as a “rule” on which to base your decision making. A good example is basic life support. You know the drill (or you should- it’s mandatory!) There are benefits to having a rule. It’s fast. It standardises the decisions. If everyone knows the same guideline, then you can work together as a team. You don’t need to sit down and think- someone else has done the thinking for you.

There are buts. You know there is a guideline for cardiac arrest. What about the one for anaphylaxis? Or escalation of the deteriorating patient? Or the guideline for pre-eclampsia, or diabetes, or needle stick injuries, etcetera etcetera… The trouble is, you need to know there is a rule to follow it. You also need to be able to find that rule. Have you tried looking for a guideline on hippo? It’s not always easy.

Other drawbacks? It doesn’t allow you to think “out of the box”. Guidelines can sometimes be too rigid. Some guidelines are complex, and so easily misunderstood. In these cases, it might be most appropriate to have a copy of the rule to hand as you are carrying out the task. Also you can apply the wrong rule if you have picked up the cues wrong. It wouldn’t be the first time that a patient had been “defibrillated” because an ECG lead was hanging off…

Novel Solutions

While we are on the topic of “thinking out of the box”, we can take a quick look at this one. Novel solutions are things we think up on the fly when there isn’t a solution readily available. An example would be using a tongue depressor to splint a baby’s arm. These solutions are occasionally a necessity, but most likely to result in unintended outcomes.

4: The BBC substitutes sarcasm with inverted commas as the lowest form of wit

Recognition Primed

Which brings us last, but not least, on to recognition primed decision making. It’s that pattern recognition thing. You walk in to a room and immediately just know what’s wrong. This way of thinking was described first when firefighters were being observed. When asked afterwards how they came to a decision, they would say only one option would come to mind, not a whole list like in classical option appraisal. They would then run with that idea, assessing at intervals whether the decision was having the intended effect.

This is how most of us do it. We make a decision from one single best fit option. The major benefit is that it is fast, sometimes supernaturally so. It doesn’t require much mental effort, and so is resistant to stressful situations. However, it is more likely to be wrong than a good sit down and think. In other words, some of your most experienced team members are more likely to be wrong because their pattern recognition has short circuited their decision making process. Be aware of this.

Thinking biases

There are other factors that can affect how we make decisions. Our decision making may be entirely rational, but there are biases that creep in to trick us. Here are some examples:

• Confirmation bias. Take a diagnosis of bleeding for example. We tend to look for the symptoms and signs that confirm our diagnosis. We see the increased heart rate, the decreased blood pressure but ignore the wheezy chest that tells us the diagnosis not bleeding. This is a common failing when humans make decisions. Remedy? Take the symptoms that don’t fit seriously, and do not dismiss them.
• Premature closure. In a similar vein, if we make a diagnosis, we stop looking for another diagnosis. Again this is common, and can often lead to missed problems. Remedy? First, use forcing functions, like writing a list of possibilities rather than just one option. Second, continually review your decisions especially in the light of changes.
• Attribution bias. If something looks like a duck and quacks like a duck, we assume it’s a duck. So if someone looks and acts drunk, we assume he is drunk. Even if his symptoms are caused by a subdural haematoma. Remedy? Look for the facts to either corroborate or contradict your duck theory.
• Base rate neglect. If something looks like a duck and quacks like a duck, don’t assume it’s a Christmas Island Frigatebird. Oddly, sometimes we do ignore the most common things and decide to pick the least likely option. Remedy? Assume it’s a duck. No wait…

5: Not a duck

H.A.L.T .

Our decision making may not be rational. We are human beings and there is most often more than one set of values at play. Decisions are often made when we are Hungry, Angry, Late or Tired. Or indeed is there some other conflict? Do you dislike the person you are making a decision for? Do you disagree with a senior colleague? This happens all the time. A couple of months ago I saw a patient in the emergency room with a head injury. The long and short was that his conscious level was decreased and he needed transferred to Edinburgh. The options were I could take him, or he could go with a nurse transfer. But I’d already been working for 12 hours by this point; the transfer to Edinburgh always takes 5 hours, and it was arguable that he was well enough to go with a nurse rather than an anaesthetist. Ish.

So the decision was made to transfer with a nurse (sorry Sarah). But I second guessed myself and phoned a friend. After discussion, he said “Well, if it was me, I’d go…” So I sloped back to the emergency department to find the patient already out the door! Further decisions were punctuated by interesting vernacular; suffice to say, I ended up in the back of an ambulance after some less than elegant decision making.

What can we learn?

On reflection, there are several things we could learn from this. We need to be aware when we are making decisions. This allows us to think how we are making decisions- is it recognition primed? Is it option appraisal? We can think what aids there are to help us such as rules or guides. We must realise what barriers are in the way of our decision making. Things like hunger, anger, lateness or tiredness can all be dealt with to improve our decision making.

Any last tips? Often it helps to stand back and take time to weigh the options. A colleague can be a valuable resource. If a decision is not clear, talk to someone about it. Possibly most helpful of all, it is important to reflect after the fact. What decision did I make? Did it have the desired effect? Could I improve on it next time?

Do you make good decisions?

David Macnair is a Consultant Anaesthetist at NHS Dumfries and Galloway