I think all healthcare providers would do well to read this from time to time, and ask themselves where in their work they or their colleagues might be deviating from these principles, and what they could or should be doing to more closely adhere to them.
The Physician’s Pledge
AS A MEMBER OF THE MEDICAL PROFESSION:
I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;
THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;
I WILL RESPECT the autonomy and dignity of my patient;
I WILL MAINTAIN the utmost respect for human life;
I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient;
I WILL RESPECT the secrets that are confided in me, even after the patient has died;
I WILL PRACTISE my profession with conscience and dignity and in accordance with good medical practice;
I WILL FOSTER the honour and noble traditions of the medical profession;
I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;
I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;
I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;
I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;
I MAKE THESE PROMISES solemnly, freely, and upon my honour.
Have you deviated from any of the above?
Can you resolve not to in future?
What help do you need from your employer or your colleagues to allow you to adhere to them?
Can you think of colleagues who might benefit from being shown this pledge?
Please reflect on this line:
I will attend to my own health, well-being, and abilities in order to provide care of the highest standard
It is ABSOLUTELY RIGHT to prioritise these so you can be maximally effective for your patients.
If there are changes you need to make in this area, make them.
“What’s your leadership style Cliff? How do you like to run the emergency department?”
Our new fellow had asked a reasonable question. Although I’d never had to summarise it before, my reply came immediately: “I see my role as doing the most for the most by reducing the sum total of human suffering in the ED – both patients and staff”.
I hadn’t really reflected on this before. Obviously my clinical priority is resuscitation, but the reality is that resuscitation only contributes to a small proportion of ED workload. And when our resources and attention are prioritised to the resus room, the department fills with other patients in pain or distress, and their anxious relatives and parents(1).
Examples of the suffering, in patients, relatives, and staff, include:
Emergency departments really can be melting pots of human suffering, but there is so much we can do to reduce or relieve that suffering. We just need to expand our view of our role from ‘diagnose and treat illness’ to ‘care for patients and their families’.
I believe an emergency physician can do much to reduce the ‘area under the curve’ – from listening to the nurses, buying a round of coffee, making sure rest breaks happen; to relieving pain, thirst and cold; to trying to prevent illness and injury from claiming someone’s loved ones; to being understanding to an admitting specialty colleague; to taking the time to explain to parents and relatives what is going on, and that you are taking their presentation seriously.
How I believe we can influence human suffering in the ED.
This is a graphic to illustrate a concept, not a graph based on data.
I also believe this approach provides some protection from burnout. It is easy to be concerned with the difficult aspects of our job that are outside our control, which can result in stress and a sense of powerlessness. But there are so many things WITHIN our control that can make such a difference, that this is where our attention should focus. This is the ‘Circle of Influence’ described by Steven Covey in “The 7 Habits of Highly Effective People”, in which he argues that the first habit, Proactivity, is demonstrated by people who work on problems within their circle of influence, rather than wasting time on those things outside it. Not only will this provide us with more satisfaction and sustainability in our career, it should also make us happier people, since expressing kindness for other people is a key component in the recipe for human happiness (which I describe here).
Of course, the other staff can also make a massive difference. However as the emergency physician clinically in charge of the floor, I have a responsibility to lead by example, and can exert far greater influence than more junior staff. As summarised recently by Liz Crowe and colleagues(2):
“EM doctors as the leads of the ED often set the ‘tone’ for the interdisciplinary staff within the team. Each EM doctor can choose to actively contribute to building a safe and supportive culture of collegial
support, professional development and learning through high quality communication, humour and creating a sense of team within their departments.”
So let’s ALL set the tone. Support our teams, and show kindness to them and our patients. We can all help reduce the Area Under the Suffering Curve.
1. Body R, Kaide E, Kendal S, Foëx B. Not all suffering is pain: sources of patients’ suffering in the emergency department call for improvements in communication from practitioners. Emerg Med J. 2015 Jan;32(1):15–20.
They say emergency medicine and critical care are no picnic, but I’ve been trying to change that. There’s something about sitting down on a blanket and sharing protected time for conversation that makes for good team building and effective communication. If you have snacks, it’s even better.
In the emergency department or intensive care unit one sometimes has to be opportunistic regarding finding time for teaching, debriefing a resuscitation case, or even eating. We end up doing these things (if at all) on the fly, in a rushed manner, and often standing up. Do we really have to? All you need for a picnic is a blanket, a floor, and some people. Hospitals have these. If you don’t want to be seen, pop outside or use a bed space with a curtain round it.
Here’s an example of an impromptu picnic. It was late in the evening, early 2013. After two busy resus cases, my senior registrar and I debrief picnic-style, with potato chips from a vending machine and a nice pot of tea. We’re still in the ED and available to our team, but anyone can clearly see we’re in the ‘picnic zone’ and so we’re left alone for ten minutes to gather our thoughts and identify any learning points. The ED is usually a factory of interruption, but no-one wants to interrupt a picnic.
Here’s resident teaching. We don’t have time to leave the ED, but there’s always time for a picnic, during which we cover a surprising number of critical care topics. People won’t fall asleep while picnicking.
And here’s a picnic with the intensive care trainees outside the unit. This is actually lunch, but why shouldn’t lunch be a picnic once in a while?
We’re encouraged to practice mindfulness and take mental time out as a way to prevent or manage stress in the critical care environment. I think this is enhanced with an accompanying brief physical time out too. One person sitting on a blanket on the floor might be a weirdo. Get two or more people, and you have a picnic. Everyone loves a picnic.
Don’t miss your chance to register for the best emergency/prehospital/critical care conference out there
Tickets will be released on the following dates:
Here are a few ‘rules of the game’ from the course organisers:
There will be 3 separate ticket releases: the major release will be as above on Wednesday, 26th October, a smaller allocation will be released on Wednesday, 7th December and a final limited release on Wednesday, 1st February
Your best chance will be with the first release, but if you really need to wait until you have leave confirmed then you can chance your hand on the February release
All prior delegates will receive an email reminder the week before tickets go on sale, but there is no other preference (first in best dressed!)
Owing to the limited number of spots there will be no DAY ONLY registrations issue
Workshop registration also opens on Wednesday, 26th October and like last year will be on a first come first served basis
If you miss out on a ticket there will be a waiting list
If you miss your preferred workshop there will also be a waiting list
You can check out the program here and registration fees here
Don’t worry if you can’t make it – all smacc talks are published free on line and you’ll find talks from the last four conferences at the smacc site
I’ve always had strong feelings about education. I was an uninspired and underachieving medical student, exasperated at the fact that the preclinical course at my medical school consisted of lengthy lectures about detailed aspects of basic sciences like histology and embryology. To make it worse, the teaching was delivered by basic science PhD students who were required to teach medical students as part of their contract. They taught because they had to, not because they were good at it. In other words, the best way to summarise how I was initially taught to be a doctor is this: my medical training consisted of being taught stuff I didn’t need to know, by people who weren’t doctors, and who didn’t know how to teach.
This frustrated me enormously. It wasn’t until I hit the wards as a senior medical student and then junior doctor that I would occasionally run into enthusiastic and supportive clinicians who were keen to share what they knew. They seemed to be few and far between, but the crumbs they dropped were enough to leave a trail that led me to be determined to become a doctor who could similarly inspire and motivate others to love learning.
Throughout my training I made a consistent observation: a small amount of good education was extremely motivating. The converse was also true – being denied access to education was extremely demotivating. In one department, teaching was continually cancelled due to patient load. When questioned on this, the clinical director stated “teaching is a privilege, not a right”. This influenced me profoundly, because I immediately adopted that phrase as a personal motto, except that I flipped the order of “right” and “privilege”.
A few events have converged this week to remind me of the power of good education. The first, and most important, was when my friend Rob Rogers, a renowned emergency medicine educator who has run courses on how to teach all over the world, tweeted a picture of an interesting ECG.
Rob and his team have inspired so many people with their brilliant education. Faced with a life-threatening ST-elevation MI, Rob chose to share his ECG with his Twitter followers. Later he shared details of his angiogram pre- and post-revascularisation. Now THAT is commitment to education!
The second event this week is that we are running our Sydney HEMS induction course in prehospital & retrieval medicine. This is about as full on as medical education can get, with hours of simulation, testing, and stress exposure. I am constantly amazed at the dedication and hard work of my colleagues who make up the course faculty, and the willingness of the participants to go the extra mile to improve their performance. We have the honour of inviting medics from certain branches of the Australian military to attend the course, and one such armed forces ‘graduate’ of our course recently contacted me:
He attached a document outlining a situation he faced which took my breath away. I’m not yet allowed to share it, but the bravery he showed was awe-inspiring. To think that he credits some of his preparation to the training we gave is truly humbling. It is also a reminder of the enormous responsibility of educators.
We can provide both negative and positive inspiration through our choices in what we say and how we say them, and in the teaching we deliver. As learners those educational experiences shape us and stay with us forever, influencing the choices we make and how we choose to pass on the teaching.
The humbling feedback from my military friend along with Rob’s ongoing desire to educate in the face of life-threatening illness serve to remind us of the power of education, and the responsibility we educators have to share, to inspire, and to provide the highest quality teaching.
Something Rob already seems to be working on, less than a week post-myocardial infarction …
@hayleybsa 8am on the 14th…working on the schedule now…Course is going to be FANTASTIC!
This talk was the opening plenary given at smacc Chicago. The title they gave me was ‘Advice To A Young Resuscitationist. It’s Up To Us To Save The World‘ but I ditched the last half because, as I point out later in the talk, I don’t think it is up to us to save the whole World. Some AV muppetry at the conference centre prevented the smacc team from being able to include the slides, so I’ll post those too at some point. You can hear the talk as a podcast at the ICN or on iTunes
This season is about giving, and yet most of us spend it giving to people who don’t need anything.
Richard Johnson and his family have a better grip on global reality. Rich is an emergency physician and retrievalist based in Australia’s Red Centre. He had a life-changing experience working in Rwanda where he was shown the difference that can be made to communities stricken by poverty when you combine a relatively small amount of money with a lot of effort and love.
You can read his full story here, which is truly inspiring. In 2004, having treated a premature infant, Rebecca, who was expected to die, and subsequently seeing her nursed to full health, Rich dedicated some of his time, energy, and money to seeing that Rebecca and other orphaned children could have a chance at a safe home, medical care, and education.
He recently returned and sent this email to his friends:
I have returned from my trip to Rwanda and have a mind spinning with thoughts and possibilities. I spent three weeks visiting families and communities and seeing very difficult things and making very difficult decisions as to who we can support and who we won’t be able to.
The level of poverty that I witnessed with overt physical signs of malnutrition, poor housing, cholera outbreaks was at times overwhelming. Even though I have lived there and seen it before it seems all the more real and vivid when it is affecting people that you know and care about.
I have left money for emergency food aid, solar lights, paid for a boat to be built and fishing net, arranged for some roof repairs to weather proof houses (it is the rainy season) and arranged for primary and secondary education for some of the children. I have also employed a local man, Prince to manage the projects on the ground and whose family will be providing residential care for Rebecca during school term times to ensure her education. He is an ex-orphan and a truly remarkable man. I will personally pay his salary, the overheads costs of the project and Rebecca’s living costs. All funds raised will go to education and community support projects.
Other projects pending are further housing improvements to allow more efficient fuel use for cooking and sanitary latrines. Water security initially using filters and eventually pumps and wells. Agricultural land investment and the setting up of food and cash crop co-operative. Fishing materials. Secondary school scholarships and board to allow long term life choices via education and qualifications. Micro-finance and investment initiatives to support local enterprises.
I will be compiling a full report for those of you who wish to read it and it will be published through our website here
I estimate that we need around $15000 to set up and between $5000-$10000 per year for ten years to achieve what we are setting out. More will allow us to expand our assistance further through the community.
We have set up a crowd funding website to receive donations so please give what you feel you can and tell everybody you know about it. For those of you in Australia who would like to contribute for whom it would be cheaper to do a direct bank transfer please contact me for my account details or postal address to send a cheque; both of these latter forms of payment can be entered manually onto the website for transparency and clarity and you will receive an email confirmation and thankyou.
As I sat in my safe comfortable house with my full belly surrounded by my well nourished, hydrated, educated and immunised family I couldn’t help be inspired by a man giving a shit and sharing his energy and resources to help those who really need it. It was a tiny effort on my part to make an online donation. I’m not going to miss a few hundred dollars but a kid gets to go to school for a year for that. The next time I see a 92 year old dementia patient from a nursing home who’s been sent in with a blocked gastrostomy tube I might stop deluding myself about the ‘massive difference’ I’m making at work and consider that truly massive differences really can be made when we contribute to projects such as Richard’s.
So if you’re wondering whether you’ve given enough this season, feel free to consider a mosquito net, or a roof, or some schooling.
I was in Edinburgh two weeks ago, examining for the Diploma in Retrieval and Transfer Medicine. From there I flew to Slovenia, where I ran a critical care course and then was invited to give a talk entitled ‘Why I Do Emergency Medicine’.
Little did I realise that I’d left behind in Edinburgh a department full of people who had also considered this question and provided an inspiring answer:
Wishing our colleagues and patients a safe and fulfilling Christmas & New Year
We’re in the business of sudden death. As prehospital, emergency, acute medicine and intensive care clinicians, facing the reality of the tragic loss of a living person, loved by their friends and family, is our day job. This makes me think we shouldn’t really have any reason to be ‘shocked’ or ‘surprised’. But we have every right to be sad.
The news came in the same week as the tragic Flight for Life Helicopter Crash in Colorado, bringing us another unwelcome reminder of the dangers of prehospital work. My HEMS colleagues and I are always mindful of the possibility that every time we get in the helicopter it could be our last, and I’ve no doubt John appreciated this reality when responding on his motorcycle.
Two weeks ago John and I gave two of the opening talks at the SMACC conference in Chicago. My talk went first – entitled ‘Advice to a Young Resuscitationist’. I attempted to list a number of tips that could help a resuscitationist become more effective at saving lives while surviving and thriving in our often traumatic milieu. The talk will be uploaded soon, and I’ve listed the pieces of advice below. What strikes me now like a slap across the face with a large wet fish is the realisation that John exemplified every one of these characteristics and habits:
1. Carve your own path that takes you on a richer path than that worn by trainees in a single specialty
John was an anaesthetist, an intensivist, and prehospital doctor.
2. Never waste an opportunity to learn from other clinicians – leave your ego at the door. See any feedback as an opportunity to learn and to improve, no matter how painful it is to receive.
Despite being among the best in his field, John would on occasion discuss challenging cases and ask if we could think of anything else that should have been done (our answer being, without exception, “no”).
3. Have the confidence and self-belief to perform actions you are competent to perform when needed, to avoid the tragedy of acts of omission.
John’s amazing talk on “crack the chest – get crucified” (when no-one else would) shows how he embraced this mindset: do what needs to be done – with honourable intentions – and manage the consequences later.
4. You can’t save every one, but you can make each case count. When a case goes wrong you need to change something – yourself, your colleagues or the system.
John was a super-agent of change wherever he operated. One beautiful example is how in one hospital the thoracotomy tray ended up being named after him!
5. Caring is so critical to what we do, and is one of the most important things to patients and their families.
As Greg Henry taught me (quoting Theodore Roosevelt) : ‘Nobody cares how much you know until they know how much you care’
John was gentle, kind, and humble. So many of his tributes remark on his compassion and dedication to patients.
7. Strive for balance in your life and your work. Consider part time working or mixing your critical care with a non-clinical or non-critical care interest.
John was revered and loved within the world of motorcycle racing, a passion he managed to combine with his flair for critical care.
8. Train your brain to be aware of and to utilise strategies that protect it against cognitive traps and avoidable performance limitations under stress – learn the hacks for your MINDWARE.
Many of us now introduce stressors into our simulation training to help us learn to deal with the adrenal load of a difficult resuscitation. But I doubt many of us can hope to achieve the intense focus and concentration under pressure that is required of motorcycle racers. John sent me a link to this video of racer Michael Dunlop a few weeks ago with the comment ‘How about this for a scare!’
9. Maintain perspective. It’s not all about you or your resus room.The most effective resuscitationists save lives when they’re not there. They work on the systems – the processes, the training, the governance, the audit, the research.
John was a brilliant educator and systems thinker. The care given at the roadside, in the ED, the ICU and the operating room at many sites is better because of the teaching he gave and the approaches he developed.
10. Understand that everything you say and do in a resuscitation casts memorable impressions in trainees’ minds like the tossing of pebbles into a pond, whose ripples reach out and out to affect so many future lives and deaths in other resuscitation rooms.
You can imagine the obstacles and personalities John faced when trying to improve care in the environments in which he worked. But through it all he remained a gentleman. Always constructive, always collaborative, always supportive. I’ve never heard him say a bad word about any named individual or criticise another specialty. He truly embodied the non-tribal spirit of SMACC, which sets an example for us all to aspire to, and will influence future resuscitation room behaviour in far-reaching locations.
11. Behave as you would want to be remembered, and be mindful of the extent of the ripples in the pond. But don’t let that put you off throwing the pebbles – embrace the challenge of the highs and lows and above all enjoy the ride, for it is awesome.
In just 35 years of life John saved the lives of many and changed the lives of many more. He knew how to throw pebbles and wasn’t afraid to point out the lack of emperor’s clothes around many traditional aspects of medical practice. And that smile seen in all the pictures of him shows there’s no doubt John enjoyed the ride, and it was awesome. Thanks to his wit, intelligence, teaching, charm, and resuscitation brilliance, he helped us enjoy it all the more too.
I spent a lot of time preparing my talk ‘Advice to a Young Resuscitationist’. It’s clear to me now that I needn’t have bothered. Sharing the stage with John, I could have saved everyone’s time by simply saying: ‘Try to be like THIS guy’.
I am extremely privileged to know him, to have learned from him, and to have shared some moments from his days at smaccUS.
We will mourn, we will remember, and we will honour him by being the best resuscitationists we can.