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Non technical skills

Burnout Prevention in Medical Professionals 150 150 Endeavour Medical

Burnout Prevention in Medical Professionals

AUTHOR: DR ISHANI RAO

Dr Ishani Rao is an NHS GP and emergency medic. After a close encounter with burnout as a junior doctor, she realised the importance of looking after her own mental and physical health, and that of other healthcare professionals.

There are several current buzzwords as we recognise the importance of addressing, managing and preventing mental health issues in medical professionals. ‘Mindfulness’, ‘resilience’, and ‘wellbeing’ are all topics that we read articles about, have training in, and get questioned on by our workplace. However, how has this come about? What is the evidence behind this, and how can we utilise these concepts to reduce burnout and stress in ourselves and our team?

Let’s start with an introduction to burnout, and how we can identify symptoms of this. The term is defined by the International Classification of Diseases as ‘a syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed’ (1). This term was only added by the World Health Organisation to the 10th revision of the disease manual in 2016. The term was originally coined in the 1970s by a psychologist called Herbert Freudenberger who observed the development of a loss of motivation, emotional instability, and pessimism in mental health workers volunteering at a free clinic for the homeless community and drug offenders in New York City (2). It encompasses a state of physical and emotional exhaustion that may be characterised by multiple non-specific symptoms. These can largely be grouped into emotional symptoms (eg. pessimism, lack of motivation, irritability, helplessness), physical symptoms (eg. pain, headaches, impaired immune system, fatigue, insomnia) and behavioural signs (eg. procrastination, isolation, substance misuse, reduced performance.) It is important to consider the interlink between the mind and the body here. We must also be aware that symptoms may manifest differently in each individual. It must be emphasised that anyone experiencing the aforementioned symptoms should be reviewed by a medical professional to ensure appropriate investigation and consideration of differentials before a diagnosis of burnout is given.

It has been consistently recognised that medical professionals are disproportionately affected by burnout, with figures suggesting that around 60% of physicians have suffered from occupational fatigue (3). At present there is a lot of conflicting evidence about whether certain specialities are affected, however when compared to other professions the increase in medical professionals is recurrent. A number of questionnaires and research methods have been used, most notably the Maslach Burnout Inventory which assesses emotional exhaustion, depersonalisation, and reduced accomplishment; the three constituents of burnout syndrome (4.) This compares to a recent estimate of 40% of the general population surveyed by the workplace consortium Future Forum (5). Contributing factors to this for the medical profession include heavy workload, variable and unsocial working hours, potential to make life-threatening errors, threat of litigation, physical and mental fatigue, and witnessing traumatic events. This has been exacerbated by the additional stressors of the COVID-19 pandemic, and recent NHS industrial action which, at the time of writing, has not been resolved.

As awareness of burnout increases, we must remember that external factors should be addressed, as well as organisational focus on our own internal resilience and mindset. Literature reviews have consistently suggested that occupational factors, rather than intrinsic personality traits or social circumstances, are the main determinant of job satisfaction and burnout rates [6]. We must consider whether employers are doing everything that they can to ensure the welfare of their employees and of the workforce. This not only benefits the mental health of individuals, but also reduces the number of clinical errors made, improves professionalism and judgement, increases patient satisfaction, improves team morale, and even reduces the number of road traffic accidents for healthcare employees [7]. It is stated by the Health and Safety Executive considerations of human factors that ‘poorly designed shift-working arrangements and long working hours that do not balance the demands of work with time for rest and recovery can result in fatigue, accidents, injuries and ill health’.[7]

Many non-medical companies have recognised that productivity is proportional to job satisfaction and have implemented free stress-reduction techniques such as gym memberships, counselling services, shorter shift times, alternative therapies such as massages and yoga, and mentoring and monitoring schemes for staff to prevent burnout from occurring in the workplace. Within public organisations, such as the NHS, there exist programs and support services for those who are struggling with occupational challenges. Studies have found that interventions such as communication programs, mentoring schemes, and modified work schedules have been effective at improving morale in healthcare workers. It is worth asking your workplace or your GP if any of these services are available to you: details are likely to be available on your workplace intranet and through your occupational health department. Some charities and organisations offer counselling sessions free of charge to frontline NHS workers. One interventional study showed that regular free aromatherapy sessions reduced rates of anxiety and improved cohesiveness in A&E nurses [8]. Further research needs to be conducted into this topic to identify effective ways that employers can improve employee satisfaction.

There are plenty of individual factors that can be targeted and encouraged in order to reduce burnout rates including effective stress management, time management, and maintaining good health, social support networks and personal care. However, any sub-optimal and unsupported working conditions have the potential to induce acute and chronic mental health issues in employees regardless of the mindset, exercise routine, or characteristics of the individual. Organisations and governing bodies should be encouraged to implement rigorous standards to protect their workforce and retain healthcare workers. At an individual level it is important to communicate with your team, line managers, and occupational health department if you feel as though they could support you better.

In the meantime, we must do our best to look after ourselves and each-other. Self-care can look like many things, and some things that might make one person feel comfortable and relaxed may be torture for others, such as cold water swimming or getting a massage! The list of things that constitute self-care is endless. Physical methods may include activities such as exercise, nutrition, eating enough fruit and vegetables, and getting enough rest. A recent study published in the journal Frontiers of Psychiatry demonstrated that individuals who reported a lack of sleep were more likely to report a recent infection and a worse immune response (9). Emotional forms of self-care can include therapy, stress management and relaxation techniques, and self-releases such as journaling. Spiritual techniques can include mindfulness and meditation. Even spending 5 minutes a day meditating has been shown to improve connectivity in parts of the brain using functional MRI mapping (10).  Cultivating social methods such as reaching out to a support system, communicating with friends, and setting boundaries (such as declining extra commitments) can be helpful to prevent burnout and occupational fatigue. We all know that it can be difficult to decline taking on another responsibility: the ‘anti-burnout club’ has a helpful guide called ‘How to say no without guilt – a guide for people pleasers’ (11). Managing work stressors with techniques such as taking regular breaks, staying hydrated, and practising breathing methods during stressful incidents has been proven to alleviate occupational tension. There is conflicting evidence regarding the role of a medical debrief, for example after an unexpected death. Some people may find that discussion and debriefing after a traumatic event at work can be helpful; however some studies find that this can exacerbate mental health issues or PTSD in certain people (10). The website ‘Life in the fast lane’ has an online article about how to manage this appropriately (12).

We are familiar with the term ‘prevention is better than cure’; so why are we leaving burnout to be managed so late? We need to break the stereotype that healthcare professionals are the worst patients. Understanding the symptoms and the best methods of prevention is imperative in addressing the growing burnout epidemic amongst our workforce.

Disclaimer: This article does not act as a substitute for medical advice – please contact a healthcare professional if you need further support.

Are you a postgraduate doctor in training? If so, why not take a look at our Remote and Restorative medicine course? This two day course focuses on restoring enthusiasm for working whilst enhancing clinical and professional skills. 

 Whilst you’re there, why don’t you take a look at our other courses too?

References

  1. Available online on the 10th revision of the International Statistical Classification of Diseases and Related Health Problems- World Health Organisation Version 2016. https://icd.who.int/browse10/2016/en#/Z73.0
  2. ‘Staff burn-out’. H Freudenberger. Journal of Social issues, 1974. 
  3. ‘Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic’. T Shanafelt et al. Mayo Clinic Proceedings, 2022. 
  4. ‘Evaluating stress: a book of resources’. Maslach Burnout Inventory, Third edition. C Maslach et al, 1997. 
  5. Future Forum: Mission Impact survery. Available online at: https://impact-mission.org/insights/future-forum/.
  6. Labour Force Survey. Statistics for Health and Safety Executive. Published online, 2016. 
  7. ‘Human Factors: Fatigue.’ Available online at Health and Safety Executive at https://www.hse.gov.uk/humanfactors/topics/.
  8. ‘The effect of inhaled essential oils on mental exhaustion and moderate burnout: a small pilot study.’ E Varney, J Buckle. The Journal of Alternative and Complementary Medicine, 2013. 
  9. ‘The association between self-reported sleep problems, infection and antibiotic use in patients in general practice’. I Forthun et al. Frontiers in Psychiatry, 2023. 
  10. Revealing changes in brain functional networks caused by focused-attention meditation using Tucker3 clustering’. T Miyoshi et al. Frontiers in Human Neuroscience, 2020.
  11. ‘How to say no without guilt- a guide for people pleasers’. Anti-Burnout Club. Available online at https://theantiburnoutclub.com/how-to-say-no-without-guilt-guide/.
  12. ‘Clinical debriefing’. Life In The Fast Lane. Available online at https://litfl.com/clinical-debriefing/).
Communication Methods on Expedition 150 150 Endeavour Medical

Communication Methods on Expedition

AUTHOR: DR DOMINIC QUIGLEY

Here we discuss the importance of communication whilst on expedition: how to perform this appropriately and effectively, both within the team and with the wider world. We will outline some principles of face-to-face communication and leadership skills, before moving on to discuss technological communication devices, specifically looking into their uses and appropriateness whilst on expedition. This will help to guide you in how to effectively engage with your team members, and also recognise when and how you will need to contact those outside of your expedition team, whether that be friends, family, or the emergency services.

What is the importance of communication?

When thinking about expeditions, good communication is fundamental throughout the entirety of the endeavour; from planning to execution as well as an effective debrief on returning. Having good face-to-face or interpersonal communication can determine whether or not the team works well together, whether you are all working for the same common goal, and ultimately the success of the whole expedition. It can instil confidence within the group and individuals, ensuring that they will be valued, respected and heard, making them more likely to highlight areas of concern throughout the expedition. 

Communication methods in themselves will also make up a separate, vital, part of your planning stages. You will need to ensure that you and the rest of the team all have suitable means of communication with the world outside of the expedition and that, importantly, everybody is trained in how to use it. This will need to be a carefully discussed topic, as certain means of communication may have severe limitations depending on where you are going and some may even be illegal in certain locations.

Planning

During the planning stage of the expedition it is important to consider the two types of communication, internal and external communication, and when these may be required throughout the journey. 

Internal Communication

Internal communication will be the everyday communication between members of the group on expedition. This will be used to identify goals and objectives, relay instruction and directions, and resolve conflict or discrepancies. It is recognised that teams with strong communication skills are better equipped to adapt to changing circumstances and plan more effectively by ensuring trust, confidence and safety (1). You will need to discuss and agree as a team how best to communicate whilst on expedition and who will be responsible for giving overall direction to the group. 

You may also want to plan for communication styles to change, whether that be during a training exercise or should something go wrong, and how everyone will be expected to communicate following this. A worthwhile endeavour is assigning buddies between the group: these do not have to be close friends. However, someone’s assigned buddy is responsible for checking in on them each day and communicating issues, conflicts, or problems to the leader should the participant be too tired or embarrassed to do so themselves. 

External Communication

External communication is the communication your group/expedition will have with the outside world whilst away, including with team members ‘back at base’ or in their home country. This will be one of the key planning steps as everyone may need to have their own form of communication and understand the limitations with it. Depending on where you are going and who is in your group, certain members may need to undergo additional training to use specific communication tools or technologies. 

Within the planning stages of an expedition, it is important to develop or be aware of appropriate guidelines for the below communications. The appropriate modality of communication in terms of technology should also be considered. External communication on expedition may comprise of:

  • Routine communication: updates to family and friends, social media use or blog posting
  • Checkpoint communication: when during the expedition the group is specifically detailed to check in with home
  • Emergency communication: only to be used in emergency situations
  • Backup communication: what to do should communication tools be lost or damaged 

To further aid in emergency communication, when planning you will need to ensure everyone has printed and digital copies on their person of the items below and that the group leader has copies for everyone of the most vital documents (2). It is worth reinforcing that digital copies and printed copies should be taken in case of missing/stolen kit, or lack of electricity/internet access. 

  • The British Embassy in the countries you are travelling to 
  • Emergency family or friends contact details
  • Insurance details (including policy number and contact details)

Internal Communication on Expedition

Internal communication will encompass all forms of communication within the team. This includes: 

  • Face-to-face (verbal and non-verbal) 
  • Written including paper-based, text message or email
  • Radio communications 
  • Whistles and other emergency communication (smoke, light, etc.)

During the expedition you will assign a group leader, although be prepared for others in the group to take on greater or lesser leadership roles during distinct episodes of the expedition (i.e. preparatory, in-country, returning, emergency) (3). This person(s) will be in charge of relaying the goals and objectives for the hour, day, or week to the group and ensuring regular check-in with the team. They may also be responsible for communicating changes in plans, or resolving conflict within the group. To do this, we would recommend using specific communication tools such as:

  1. SMART when defining goals (specific, measurable, achievable, relevant and time-bound) – this allows you to create and communicate specific goals to the team with clear timeframes and actions.
  2. Active listening when involved in disputes – by using verbal and physical communication to show you are listening during a discussion. 
  3. Chunking-and-checking in conversations/plans containing lots of information – this allow you to check that everyone is following the plan, despite the length of the information that may need to be relayed. 
  4. Negotiation when dealing with conflict resolution – this will help you to reach a compromise more quickly.

When discussing with the group, this should be done face-to-face at the beginning of the day, but may require radio communications, texts, or emails throughout the day/activity. As such, all team members should understand the basics of radio communications if this is what you intend to use. 

The team leader may be responsible for communication during training exercises and emergency situations. Generally, training exercises should be clearly communicated and outlined with phrases such as “this is a training exercise”, and safety phrases should be set out in the event of an accident – i.e. “we have a live accident”. Should an accident occur, team members should be aware of emergency communications (such as whistles, smoke, or light) and communication tools such as SBAR (situation, background, assessment, recommendation) and METHANE (used specifically in declaring and managing major incidents (4)), as these may be vital in effectively communicating the situation between members. 

It is not only important to think about what is being communicated, but also who needs to be involved in the communication. If an emergency situation arises, not everyone may need to be involved in the decision-making and some information may need to be restricted from the wider group. This may require a small group separating to discuss it in person, or changing radio frequencies if using hand-held-communication tools. Importantly, you may wish to plan for a ‘communications black-out’ in certain scenarios, such as to ensure safe evacuation of a casualty and the ability to update their family before the wider party, news or social media distributes information.

External Communication on Expedition 

Technology will need to be used to communicate with the outside world during your expedition. It is important that you fully assess what types you will need depending on where you are going and what you plan on doing. Family and friends may require regular check-ins and you may want to share your adventure on social media. For this you may need voice, data and messaging capabilities or just some of these functionalities. During the planning stage you will need to define which tools will be used for routine, checkpoint, emergency, and backup communication, based on the limitations you expect to encounter on expedition and of the technology itself. This could include issues with coverage, terrain or environmental/social/legal concerns. 

We will discuss some equipment options below, however, it is worth consolidating your knowledge and requirements before going anywhere to ensure you are taking the correct kit.

Mobile Phones

Mobile phones are great for social media updates, regular communication and even emergency situations, but should not be the only tool of communication you rely on. Network coverage is rapidly improving globally and they can be used almost anywhere in the world, but can be unreliable in less developed/remote areas. By buying an in-country SIM, you may be able to run them affordably whilst away. 

However, they are limited by battery life and rely on line-of-sight communication with provider masts. This can mean that if there is no mast close by or if you are in dense jungle, deep valleys, or some other form of coverage, you may have no signal in an emergency. They are known to shut down in extreme temperatures and many will break if dropped, submerged in water or otherwise damaged. 

Satellite Phones

Satellite phones transmit messages to satellites in the Earth’s orbit and relay them back to the designated recipient. There are two main types (Geostationary and Low Earth Orbit) with four main providers, and they work almost anywhere in the world (however only Low Earth Orbit provides coverage in polar regions). They are incredibly beneficial in emergency situations, however, they have significant disadvantages. 

Firstly, they are very expensive to use: this may include a cost for the handset, subscription, and usage. They also require direct line-of-sight to the satellites they are using and as such, may not be functioning effectively in dense jungles or within buildings or emergency shelters. Finally, in certain countries they are illegal to possess and use, and may result in criminal convictions. Therefore, make sure you check before you pack one (5,6). 

Personal Locator Beacons 

Personal Locator Beacons (PLBs) are devices specifically used in emergency scenarios. They transmit radio signals that are picked up by satellites and ground stations for use in emergency situations only. They have extremely long battery lives and can be used easily in most situations. 

However, they can incur costs if activated or subscription fees whilst they are in use and require you to register the device with the provider and in the country you are travelling to prior to your journey. You will also need to update the contacts registered to the device, including those in your party. Finally, some of these devices are not two-way communicators and as such, once activated there is no guarantee that help is coming. On these devices one is also not able to relay the seriousness or the type of help required. Therefore, they should only be used in extreme situations.

Overall, it is vital to recognise the importance of robust communication whilst on expedition. Within your planning stages you should always consider the various types of internal and external communication you and your team are planning to employ, and you should ensure that everyone has suitable training to allow them to utilise whichever form they require effectively. You must also make sure that you have back-up forms of communication, and a plan for when you and your team are planning to check-in with those at home, and how you will do this. This allows your group to be tracked appropriately and will help guarantee your safety whilst on expedition. 

Take home messages

  • Plan for your internal and external communication needs prior to departure
  • Define what forms of communication you will use for:
    • Routine communication
    • Checkpoint communication
    • Emergency communication
    • Backup communication 
  • Define who needs access to which forms of communication and when they might require it
  • Ensure all those that require it are trained in using the communication tools they may need prior to departure 
  • Have backup plans for events in which technology may fail and ensure the group are aware of them

Are you interested in learning more about communication and other non technical factors?

If so, why not check out our Remote and Restorative course? Whilst you’re there, why don’t you take a look at our other courses too?

References & Further Reading 

  1. SKAA49 Monitor and manage communications during an expedition. (n.d.). Available at: https://www.ukstandards.org.uk/PublishedNos-old/SKAA49.pdf [Accessed 26 Jun. 2023].
  2. www.rgs.org. (n.d.). Royal Geographical Society – Gap year planning toolkit. [online] Available at: https://www.rgs.org/in-the-field/advice-training/support-for-students-and-gap-years/gap-year-planning-toolkit/communication-and-responsible-travel/ [Accessed 26 Jun. 2023].
  3. lespretentieux (2021). Expedition Planning. [online] Base Camp Connect. Available at: https://www.basecampconnect.com/expedition-planning/ [Accessed 26 Jun. 2023].
  4. Cory Jones (2018). Major Incident Management (METHANE) – First Aid Training Cooperative. [online] First Aid Training Cooperative. Available at: https://firstaidtrainingcooperative.co.uk/major-incident-management-methane/.
  5. The Wilderness Medic. (2020). Don’t know your GSM from your PLB? Read on to learn all about communications on expedition… [online] Available at: https://www.thewildernessmedic.com/post/don-t-know-your-gsm-from-your-plb-read-on-to-learn-all-about-communications-on-expedition [Accessed 26 Jun. 2023].
  6. www.outfittersatellite.com. (n.d.). Countries with Satellite Phone Restrictions – Blog. [online] Available at: https://www.outfittersatellite.com/Countries-with-Satellite-Phone-Restrictions_b_11.html [Accessed 26 Jun. 2023].
Heuristics 150 150 Endeavour Medical

Heuristics

AUTHOR: JORDAN HARGREAVES

Heuristics, from the Greek heurískō meaning “to discover”, is the cognitive process of making decisions quickly based on a relatively small amount of available information. Psychologists Dr Amos Tversky and Dr Daniel Khaneman developed the study of heuristics in the 1970s based on the work of Cognitive Psychologist Dr Herbert A Simon. Khaneman theorises that when we make decisions we do it one of two ways: System 1 thinking, which is fast, instinctive and relatively subjective; and System 2 thinking, which is slow, analytical and considered more objective. When we need to make a decision quickly we typically use system 1 thinking; it’s automatic and requires the use of heuristics[1]. Think of a heuristic as a shortcut which allows you to generate a sufficient solution when a perfect one is not attainable within the restraints of the situation[2] such as clinical decisions being made in resource-poor environments.

Since the publication of Khaneman and Tversky’s work, several books have been released highlighting how heuristics can actually be very reliable with the right application and should be harnessed as a tool for fast decision making. For clinicians, this seems like the holy grail given that many of the important decisions we make are quite literally life or death, under high pressure, and often with large amounts of information to process simultaneously. 

As highlighted by Malcolm Gladwell in his book “Blink”[3], our intuition can be unreliable and open to unintentional misdirection. This article will discuss this topic in more detail, expanding on what heuristics are, how we affect them, and how we can mitigate them.

The Horse, The Duck & The Cognitive Bias

Heuristics come in many forms. The ones you may be most familiar with in the medical world are adages we tell ourselves to help make decisions; for example, “if you hear hooves, you think horses not zebras” meaning common things are common, similar to the phrase “if it walks and talks like a duck, it’s a duck”[4].  Although these mental shortcuts are used by clinicians all the time, they are not flawless. Tversky and Khaneman explained that the shortcuts used to make a decision can get us to the right end point quickly but occasionally send us ‘off course’[5]. This is because, although hoofbeats are usually a horse, there may be a time when your heuristic tells you ‘that’s gotta be a horse’ when it’s actually a zebra clip-clopping along. 

Imagine you’re flying home after a diving expedition. After reaching cruising altitude, one of the dive team starts complaining of a headache and photophobia. You go over to help. They tell you the headache is the worst one they’ve ever had. You recall a case you were told at the dive centre with a similar presentation and think that it’s probably decompression sickness given that she’s been diving recently and you’re now at altitude. Simple, right? Common things are common and this is a known risk to divers. However, jumping the gun without a full history and examination means you miss important differentials including subarachnoid haemorrhage or meningitis. 

Cognitive biases influence all our decisions and the above example shows how they can make heuristics unreliable. Specifically, the above case demonstrates priming and availability bias where the fact that you’ve been diving recently and can easily recall a case of something similar that fits means you disregard other key bits of information such as the fact that it’s been more than 18 hours since the dive and the cabin is pressurised, both of which make decompression illness less likely[6,7]. Our biases, though unintentional, can misguide our judgement and make us follow the path that looks familiar. Recognition of these biases allows their mitigation and considering what we could be missing as a result of them can aid our decisions.

Dr Chris Drew has an article on his website summarising 22 types of heuristics, we recommend you give it a read here: https://helpfulprofessor.com/heuristics-examples-types/

The ER problem

Heuristics are decision-making tools which focus on a few pieces of information and ignore the rest to come up with a solution. By doing so, a decision is made much quicker but ultimately sacrifices ‘optimisation’ of the solution as they are limited to the knowledge, experience and bias of the person making the decision.

Algorithms are standardised steps designed to streamline decisions by also only taking into account only a few bits of information. However, these differ from heuristics as they are often designed based on the available evidence and best practices in a given field. 

In the late 90s, Chicago’s County Cook Hospital had an issue in its Emergency Room (ER). Diagnosing acute coronary syndrome (ACS) in patients coming to the ER with chest pain but no ST-segment changes was extremely difficult whilst waiting for troponins to come back, if they could even be tested for at that time[3]; As clinical judgement was the only tool immediately available, 90% of patients with chest pain would end up being assigned to the coronary care unit (CCU) with only around 25% of patients actually having confirmed ACS. The high rate of false-positives meant the unit became overcrowded. The staff were overworked and patient safety suffered massively. 

So, if you’re an overworked, underfunded hospital being crippled by patient overcrowding, what can you do when you’re heading up a very specific creek without a paddle? Well, two scientists from Michigan University, Green and Mehr, had an idea. To reduce the burden on the hospital, an algorithm was created for physicians which focused on three specific pieces of information.

  • Firstly, were ST changes present? If yes, they were admitted to CCU immediately.
  • If not, the following question was asked: Is chest pain the principal complaint? If not, they went to a ward bed for observation.
  • If chest pain was the principal complaint, they asked the third question: Are any of the following predictors present: Previous MIs, efficacy of nitrates, or T wave changes? If no, the patient would go to an observation bed, but if yes to any of the predictors, these patients were admitted to CCU.

The result? Unnecessary admissions to CCU dropped and patient outcomes improved[3]. 

This wasn’t a perfect solution and errors still occurred but, for a hospital that was overcrowded, understaffed, with exhausted clinicians and haemorrhaging money through unnecessary high-dependency bed use, the perfect solution wasn’t available. This algorithm reduced the required time and ‘bandwidth’ for physicians to make decisions by simplifying which information was required. Additionally, by making hard and fast rules about what information should be considered, the effect of an individual physician’s heuristics and bias are mostly mitigated. Algorithms are now common in place within healthcare and a vital part of acute medical treatments; one study from the US demonstrates evidence that adherence to cardiac arrest algorithms has a positive correlation with return of spontaneous circulation[8]. 

The Ottawa Ankle Rules [9] and the NEXUS Spine Rules [10] are invaluable tools for ruling out ankle fractures and cervical-spine injuries, respectively. Though they are scoring systems instead of algorithms, their effect on decision making is the same: they reduce the effect of bias, human factors, and the bandwidth required to make a clinical decision; for example, a member of your party has a bad fall whilst on the side of a mountain and you’re worried they’ve damaged their c-spine. In poor weather conditions with frantic group members, the call to immobilise the patient and attempt extrication to an evacuation point carries risks to yourself and your group. NEXUS spine rules have a sensitivity of 99.6% for cervical-spine injury in those under 65 years old [10], so can quickly aid your clinical decision through 5 simple questions thus helping to reduce the overwhelming information overload that stops you making a decision.

Human factors play a massive role in our decision-making process too; if in the above case an evacuation would be extremely costly to your employer and end the trip of a lifetime, the effect of social facilitation to not be the person who ends the trip could further lead to analysis paralysis[11]. Having an algorithm or set of rules to follow takes societal pressure out of the equation, facilitating an objective, patient-centred clinical decision.  We recommend you read our article on human factors for more information on this.

Take home messages

Heuristics are shortcuts we use to make a decision. These are done by focusing on specific pieces of information and disregarding the rest.

Heuristics are general rules: general rules apply generally. As a result, they should be treated as such and the potential for error should be recognised.

Cognitive bias can affect our heuristics: our disregard for information that we deem unnecessary can be a huge source of error. Recognising we have these biases can help us mitigate them by considering what we could be missing.

Algorithms and scoring systems are immensely useful in resource-poor settings. Their use minimises the required bandwidth and can provide evidence-based assurance to your decisions.

Are you interested in learning more about heuristics and other non technical skills?

If so, why not check out our Remote and Restorative course? Whilst you’re there, why don’t you take a look at our other courses too?

Further reading

References 

  1. Marewski, J. N., & Gigerenzer, G. (2012). Heuristic decision making in medicine. Dialogues in Clinical Neuroscience, 14(1), 77–89. doi:10.31887/dcns.2012.14.1/jmarewski
  2. Kahneman, D. (2011). Thinking fast and slow. U.K: Penguin Books.
  3. Gladwell, M. (2005). Blink: The Power of Thinking Without Thinking. New York: Back Bay Books/Little, Brown & Company.
  4. Goldsmith, P. (n.d.). Retrieved from https://mdujournal.themdu.com/issue-archive/summer-2019/cognitive-bias-and-diagnosis-heuristics
  5. Khaneman, D., Slovic, P., & Tversky, A. (1982). Judgment under Uncertainty. doi:10.1017/cbo9780511809477
  6. de la Cruz RA;Clemente Fuentes RW;Wonnum SJ;Cooper JS; (n.d.). Retrieved from https://pubmed.ncbi.nlm.nih.gov/28846248/
  7. Feldman, J., & Cooper, J. S. (n.d.). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499855/
  8. McEvoy, M. D., Field, L. C., Moore, H. E., Smalley, J. C., Nietert, P. J., & Scarbrough, S. H. (2014). The effect of adherence to ACLS protocols on survival of event in the setting of in-hospital cardiac arrest. Resuscitation, 85(1), 82–87. doi:10.1016/j.resuscitation.2013.09.019
  9. Stiell, I. G. (1994). Implementation of the ottawa ankle rules. JAMA: The Journal of the American Medical Association, 271(11), 827. doi:10.1001/jama.1994.03510350037034
  10. Hoffman, J. R., Wolfson, A. B., Todd, K., & Mower, W. R. (1998). Selective cervical spine radiography in blunt trauma: Methodology of the national emergency X-radiography utilization study (nexus). Annals of Emergency Medicine, 32(4), 461–469. doi:10.1016/s0196-0644(98)70176-3 
  11. Thacker, J. (2021). The human factor in mountaineering and snow sports – going beyond facets. Retrieved from https://mountainassurance.co.uk/2020/10/06/the-human-factor-in-mountaineering-and-snow-sports-going-beyond-facets/
Teamwork 150 150 Endeavour Medical

Teamwork

AUTHOR: DR JENNY BAKER

You are part of a team trekking the Sinai Trail, a 550km walking trail in Egypt. The trek is going smoothly and it feels like the perfect team; you get on well, support each other through the harder, mountainous days of walking, and have naturally settled into roles when navigating and setting up camp. However, 3 weeks into the walk, the water drop-off you had arranged falls through. You know that there may be a water source during the following days’ walk but the season has been particularly dry and this is not guaranteed. It’s two days before the next guaranteed water supply. How would you address this as a team?

Teamwork is the collaborative work of a group of people to achieve a common goal; a level of interdependence within this group of people to achieve the goal creates a team. The importance of teamwork in providing good patient care is highlighted across the spectrum of medical practice, from the General Medical Council Good Medical Practice guidelines to questions within interview and appraisal processes. In the expedition world, an article about rescue efforts at Everest Base Camp and the surrounding area following the Nepal earthquake in 2015 focuses on the action of teams rather than individuals. In summary of these efforts, Zafren and colleagues (1) reflect that people must work together in order to achieve big things.

The function of a team is affected by the composition of individual factors such as age, gender, culture and expertise, and interpersonal factors including leadership, group cohesion and communication. For more on communication as well as how human factors and heuristics can affect decision making check out our other posts on non-technical skills here. This article will focus on the effect of group cohesion on teamwork.

An expedition team is often formed of a diverse group of people but all generally have the shared aim of achieving the goal of the expedition. From a medical standpoint the priorities are two-fold: achieving the goal of the expedition; also to keep everyone safe and overcome any complications that may put the team in danger.  

Collectivism is used to describe an attitude within a team where the needs of the group are prioritised over individual needs and desires in order to achieve the collective goal. Collectivism can reduce ‘social loafing’ in which individuals do not contribute proportionately, and it increases effectiveness of the team. However, whilst group cohesion and a shared desire to achieve the common goal is necessary, in the case of group solidarity you can have too much of a good thing…

Back to our case: The leader of the group, not formally appointed but had been the one to suggest the trek and had naturally taken charge, suggests that you continue walking; you can just drink less than the previous days and hopefully there’ll be a chance to refill at the spring tomorrow. Everything has worked so well as a team so far so no one considers other options or wants to disagree with them. You continue walking but it’s very hot, and when you get there the spring is dry. Having less water also means that you can cook less food and walking becomes very difficult. You meet a Bedouin tribe who are able to contact someone from the next village who brings you enough water to complete that section of the walk, but some of the group need a few days to recover and rest before continuing the trek.

Groupthink occurs when, due to high levels of cohesion within the group, individuals no longer voice concerns and/or lose the ability to think critically about group decisions made. This is particularly a problem when things go wrong. Greer and her team (2) analysed over 5000 Himalayan summit attempts between 1950 and 2013 to assess the level of collectivism within the team and its correspondence to successful summit and preventing deaths. They confirmed their findings using a laboratory-based experiment assessing team problem-solving. Collectivism and cohesion was found to be essential in ‘conjunctive’ tasks, i.e. those in which success is determined by the weakest member such as ability to summit. This was owing to equal commitment to the goal and an agreed need to support each other in order to achieve this. However, in ‘disjunctive’ tasks, whereby success is determined by the best solution provided, collectivism can become a barrier. Greer highlights that the key to overcoming disjunctive, problem solving tasks is the acknowledgment of individual skills and expertise, and the appropriate use of these when required. In the context of an expedition this may be finding the most efficient way to evacuate an injured team member or finding shelter from bad weather. Expedition teams may be formed with consideration of each participant’s skills.  Even when this is not the case, such as on a commercial expedition of individuals signing up for an ‘experience’, efforts should be made to the identify skills and experience present within the team.. Our case is an example of groupthink occurring in a highly cohesive team and demonstrates the need for teams to be flexible: while tolerance for differences is essential, at times differences in expertise should be highlighted and celebrated. . Groupthink can also be influenced or prevented by good communication, both prior to the event, and in case of something going wrong. 

Factors affecting teamwork are extensive and complex, increasingly so as each team has a unique composition of its members. The team goal is further influenced by its leader and their leadership style. The above is just one aspect to take into account when forming your team and performing as part of it. 

Take home messages

  • Teamwork is affected by individual and interpersonal factors.
  • Diversity is key within a team, alongside tolerance of these differences. 
  • Look out for groupthink, if you think things can be done better, say it! 
  • Voicing ideas in a productive and appropriate way is important.
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Are you interested in learning more about teamwork and other non-technical skills?

If so, why not check out our Remote and Restorative course? Whilst you’re there, why don’t you take a look at our other courses too?

Further reading

References

  1. Zafren K, Brants A, Tabner K, Nyberg A, Pun M, Basnyat B, et al. Wilderness Mass Casualty Incident (MCI): Rescue Chain After Avalanche at Everest Base Camp (EBC) In 2015. Wilderness & Environmental Medicine. 2018 Sep;29(3):401–10.
  2. Chatman JA, Greer LL, Sherman E, Doerr B. Blurred Lines: How the Collectivism Norm Operates Through Perceived Group Diversity to Boost or Harm Group Performance in Himalayan Mountain Climbing. Organization Science. 2019 Mar;30(2):235–59.
Human factors in Expedition Medicine and Pre-Hospital Care 150 150 Endeavour Medical

Human factors in Expedition Medicine and Pre-Hospital Care

AUTHOR: DR CATHERINE CHATFIELD-BALL

Human factors refer to the psychological, social, and organisational aspects that influence how individuals work together effectively in a team, or when lacking, can contribute to errors. These factors include communication, leadership, trust, motivation, conflict resolution, decision-making, and team dynamics. Understanding and managing these factors can greatly enhance team performance and reduce the incidence of errors, thus improving patient care. The importance of an appreciation of human factors increases as a situation becomes more stressful, or the team dealing with a casualty are more remote from help, both of which often apply in pre-hospital and expedition medicine. 

Human Factors : Safety and decision-making

Human factors as a study originated in the aviation industry and the military. In the early 20th century, aviation accidents were often attributed to pilot error. This led to the development of human factors research, which aimed to understand the cognitive, psychological, and social aspects of human performance in order to improve safety and efficiency. The military also recognised the importance of human factors in combat situations, where split-second decisions and effective teamwork are crucial for mission success. Many human factors problems arise when a person is in a state of cognitive overload; where the demands placed on an individual exceed the capacity of working memory resulting in mental exhaustion and compromised performance. This scenario is not uncommon in medicine, where there is a need to assimilate multiple pieces of information and make rapid and high-stakes decisions under stressful circumstances. 

The importance of human factors in the delivery of safe health care is now well established, with health care workers routinely undergoing education and training in non-technical skills such as teamwork and effective communication. The “Swiss cheese” model is often quoted when considering how mistakes are made despite the existence of multiple safety checks and team members. Each of these represents a layer of safety that will normally detect and prevent an error. However, if the holes in the Swiss cheese layers all line up, it is possible for an error to slip through.

human factors and swiss cheese model

Figure 1: The Swiss Cheese Model. Taken from https://josieking.org/patientsafety/module_e/swiss_cheese.html

Training in human factors aims to empower team members to identify the gaps in the care they are delivering, and subsequently reduce opportunities for errors to slip through. This has led to the development of learned communication tools such as using standardised handover systems like SBAR (a structured approach to delivering patient handovers describing Situation, Background, Assessment, and Recommendations which has been shown to improve patient safety [1]) and a fundamental shift in the paradigm of how we think of teams. Concepts such as the ‘flat hierarchy’ – which encourages all members of the team to feel able to speak up particularly if they have concerns over patient safety, are now commonplace in the healthcare system. This change, both in safety protocols at an organisational level and in how we train individuals to improve non-technical skills, has been shown to have a direct positive impact on patient safety and outcomes by reducing human error [2].

In expedition and wilderness medicine, where resources are limited and conditions are often unpredictable, understanding human factors becomes even more critical. Medical professionals working in these remote and challenging environments must be able to adapt to unique challenges, make sound decisions under pressure, and effectively communicate and collaborate with their team. Understanding how individual factors, such as personality traits and communication styles, can impact team dynamics is important for optimising performance and minimising errors. 

Objective dangers are unpredictable and sometimes unavoidable in the wilderness setting, but individuals’ response to those threats will determine the success of the trip and are governed by situational awareness, team dynamics, communication, and leadership [3]. For example, on a high-altitude expedition there is a significant chance of some members of the team experiencing Acute Mountain Sickness (AMS), which can progress to serious illnesses such as High-Altitude Pulmonary Oedema (HAPE) or High-Altitude Cerebral Oedema (HACE) if ascent continues. Recognising that a quieter individual may express feeling unwell in a more subtle way such as becoming withdrawn is key for an expedition medic. Equally, fostering a culture of kindness and collaborative endeavour within the team early in the trip is important for encouraging open communication.

Along with the demands of physical exhaustion, inherent situational dangers, and high-stakes decision making, cognitive challenges on expedition can arise directly from environmental factors, such as hypoxia at high altitude or hypothermia in the polar environment. This can affect clear thinking [4]. Unlike in the hospital setting, a team member sustaining an injury in this environment can jeopardise the whole team’s trip and even safety with the complexities of evacuation.

One of the key issues in human factors is bias, which can affect decision-making and lead to errors in diagnosis and treatment. Interoceptive bias refers to the tendency to rely on internal cues and personal experiences when making judgments, which can lead to inaccurate assessments of patients’ conditions. Conversely, groupthink is another issue that can arise in a team setting, where the desire for consensus and harmony can override critical thinking and lead to poor decision-making.

How can we improve?

As our understanding of how human factors influence team dynamics grows, so does our ability to manipulate these factors to optimise team performance. In the expedition context this can lead to improved group cohesion and a more enjoyable trip, a successful summit bid, averting a serious accident or even ensuring the survival of a critically unwell member of the team.

The issues mentioned above such as bias and poor communication can be somewhat mitigated through education and training in preparation for an expedition. Simply acknowledging that biases in judgement exist and can influence our decision-making under pressure can be enough to change behaviour – for example seeking a second opinion to ‘sense check’ our management plan for an unwell casualty in a stressful and unfamiliar setting [5]. 

Training in non-technical skills, such as leadership, situational awareness, and decision-making, can also enhance team performance in challenging environments. Simulation-based training has been widely adopted, particularly in acute specialties such as emergency medicine, anaesthesia, and intensive care, as an effective training tool for both technical and non-technical skills. Ideally an expedition group would have had an opportunity to meet prior to departure for a trip and under simulated expedition circumstances (e.g. hiking in the UK hills), allowing the team leader and medic to gauge personality types, team dynamics and cohesion, and foresee potential problems.

Research into the effectiveness of such training, looking at both objective measures of patient outcomes and at assessment of team cohesion and performance, has shown this to be a beneficial tool [6]. Simulation can be used to train emotional intelligence in recognising non-verbal cues, and communication behaviours such as closed-loop communication and graded assertiveness to challenge behaviours that compromise patient safety [7].

Take home messages

Appreciating the role of human factors in expedition and wilderness medicine is crucial for understanding and mitigating the risks associated with human behaviour, decision-making, and team dynamics in remote and challenging environments. By recognising and addressing the potential for issues such as bias and groupthink, and implementing techniques to optimise teamwork and team performance, medical professionals can provide safe and effective care in these unique settings.

There is no one-size-fits-all approach in human factors; each team with its different composition of personalities will have its own strengths and weaknesses in non-technical skills. Without doubt one of the best ways to understand and improve these fundamentals of team working is simulation prior to a trip. 

Practising these non-technical skills in simulated medical scenarios is also important. Many expedition and wilderness medicine courses now include a ‘moulage’ or casualty simulation element, to prepare candidates with not only the theoretical knowledge to manage wilderness emergencies but also provide the opportunity to put the non-technical skills into practice in the field. This affords an insight into how one performs, communicates, and leads under challenging and unfamiliar circumstances, which is critical to personal and professional development as an expedition medic.

Are you interested in learning more about human factors and other non technical skills?

If so, why not check out our Remote and Restorative course?? Whilst you’re there, why don’t you take a look at our other courses too?

References 

[1] Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. 2011; 26: 155–159.

[2] Batchelder AJ, Steel A, Mackenzie R, et al. Simulation as a tool to improve the safety of prehospital anaesthesia–a pilot study. 2009; 64: 978–983.

[3] Abrahamsen HB, Sollid SJ, Öhlund LS, et al. Simulation-based training and assessment of non-technical skills in the Norwegian Helicopter Emergency Medical Services: a cross-sectional survey. 2015; 32: 647–653.

[4] Albert E. Anatomy of a Preventable Death:“Non-Technical” Skills in Expedition and Wilderness Medicine.

[5] Wickens CD, Keller JW, Shaw C. Human factors in high-altitude mountaineering. 2015; 12: 1.

[6] Ruhomauly Z, Betts K, Jayne-Coupe K, et al. Improving the quality of handover: Implementing SBAR. 2019; 6: 54.

[7] De Decker R, Roos J, Tölken G. Human factors: Predictors of avoidable wilderness accidents? 2017; 107: 669–673.