Ian Kennedy Unmasking Medicine Ian Kennedy The New

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Ian Kennedy

Ian Kennedy

Unmasking Medicine Ian Kennedy .

Unmasking Medicine Ian Kennedy .

The New Magicians

The New Magicians

Jordan v Whitehouse 1981 All ER 267

Jordan v Whitehouse 1981 All ER 267

Errors of judgement do not constitute negligence Lord Denning, MR 1981 ‘necessary fallibility’

Errors of judgement do not constitute negligence Lord Denning, MR 1981 ‘necessary fallibility’

Errors of judgement do not constitute negligence But judgement must withstand scrutiny! (evidence &

Errors of judgement do not constitute negligence But judgement must withstand scrutiny! (evidence & logic)

‘Doctors seem now to be expected to have limitless capabilities, and the crucial role

‘Doctors seem now to be expected to have limitless capabilities, and the crucial role of human factors and systemic failures is pushed aside. ’

“It is not from the benevolence of the butcher, the brewer, or the baker

“It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own self-interest” the late Adam Smith

Atul Gawande

Atul Gawande

Why do doctors fail? • Ignorance • Ineptitude • Indifference

Why do doctors fail? • Ignorance • Ineptitude • Indifference

Indifference

Indifference

Why do doctors fail? • Ignorance • Ineptitude • Indifference

Why do doctors fail? • Ignorance • Ineptitude • Indifference

Why do doctors fail? • Ignorance • Ineptitude • Indifference

Why do doctors fail? • Ignorance • Ineptitude • Indifference

Ineptitude

Ineptitude

Incompetence

Incompetence

Wilful Blindness

Wilful Blindness

Ineptitude

Ineptitude

Cognitive Gap Knowledge < > Performance

Cognitive Gap Knowledge < > Performance

‘’Knowing is not enough; we must apply. Being willing is not enough; we must

‘’Knowing is not enough; we must apply. Being willing is not enough; we must do. " -Leonardo da Vinci

Cognitive Gap “The cognitive gap disconnects many things which are supposed to be interconnected…”

Cognitive Gap “The cognitive gap disconnects many things which are supposed to be interconnected…”

Cognitive Gap – ‘Victims’

Cognitive Gap – ‘Victims’

Why do we fail? • Too much ‘fast thinking’ and too little ‘slow thinking’

Why do we fail? • Too much ‘fast thinking’ and too little ‘slow thinking’ • ‘the curse of knowledge’

‘Curse of Knowledge’ • Counter – factual thinking; ‘Simmelweis complex’ • Dysrationalia • Earned

‘Curse of Knowledge’ • Counter – factual thinking; ‘Simmelweis complex’ • Dysrationalia • Earned dogmatism • Entrenched automatic behaviours : (Unconcscious Competence)

‘ a human being comes to another human being with their mind or body

‘ a human being comes to another human being with their mind or body troubled’ Gawande

Interaction of Frames of Reference Environment Patient's Fo. R GP's Fo. R

Interaction of Frames of Reference Environment Patient's Fo. R GP's Fo. R

A Story! • Two weeks ago viral sore throat • D 1 am –

A Story! • Two weeks ago viral sore throat • D 1 am – telephone triage with a GP – mother says he has been withdrawn, lost a bit of energy, lost a bit of weight, not known to suffer with anxiety or depression, drinking more than eating. Not clear if he is depressed or physically ill. • TCI for consultation

A Story! • D 1 pm – seen by GP - had bad sore

A Story! • D 1 pm – seen by GP - had bad sore throat with spots on tonsils 2 weeks ago. Since then fatigued and has lost weight. O/e – throat Ok, few neck glands. • Diagnosis - ? glandular fever • Inv – fbc, esr, crp, Paul Bunnell, Hb. A 1 c

and the story continues … • D 1 – night – contacted OOH as

and the story continues … • D 1 – night – contacted OOH as vomiting ; was advised to contact a GP within 2 hours • D 1 –night 15 mins later – saw OOH GPvomiting ++ , very weak; advised to go to AE immediately

and the story continues … D 1 – 1 hour later admitted with DKA

and the story continues … D 1 – 1 hour later admitted with DKA

A Story! • Two weeks ago viral sore throat • D 1 am –

A Story! • Two weeks ago viral sore throat • D 1 am – telephone triage with a GP – mother says he has been withdrawn, lost a bit of energy, lost a bit of weight, not known to suffer with anxiety or depression, drinking more than eating. Not clear if he is depressed or physically ill. • TCI for consultation

A Story! • D 1 pm – seen by GP - had bad sore

A Story! • D 1 pm – seen by GP - had bad sore throat with spots on tonsils 2 weeks ago. Since then fatigued and has lost weight. O/e – throat Ok, few neck glands. • Diagnosis - ? glandular fever • Inv – fbc, esr, crp, Paul Bunnell, Hb. A 1 c

There but for the grace of God. . . ‘Who of us has not

There but for the grace of God. . . ‘Who of us has not made mistakes that have harmed patients? ’

There but for the grace of God. . . ‘Who of us has not

There but for the grace of God. . . ‘Who of us has not made mistakes that have harmed patients? ’ ‘The then president of the UK General Medical Council, Graeme Catto, told how he still felt guilty because, as a newly appointed consultant, he delayed starting antibiotics in a young man with meningococcal septicaemia. The patient died. ’

Errors will occur!

Errors will occur!

Liam Donaldson - 2004

Liam Donaldson - 2004

Thank you !

Thank you !