Clinical iCumen: seeing the wood for the digital trees

Serious Event Review, 2020
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The doctor was running late. Her junior had phoned to say a distressed family were taking longer to counsel than expected, and that Dr Cumen would head to the meeting as soon as she could. The meeting had already been re-scheduled twice and was becoming a “gross mis-use of managers’ time”. They started the review without Dr Cumen. The manager seated at the head of the table pinged a notification to Dr Cumen’s Google Glasses to say that the meeting was available to stream and would start in two minutes. That would be fine, the End Of The Table Manager thought to herself: that way Dr Cumen could watch the review’s progress in one eye whilst listening to the family she was dealing with in her office.

End Of The Table Manager began: “Ladies and gentlemen thank you for arriving promptly, those of you that are here, for this Serious Event Review, examining the case of Patient M. This meeting will be broadcast to the Clinical Service Leads’ Google Glasses, so hopefully they will ping comment where appropriate. I’m sure you’ve all studied your briefing sheets, but Manager Of This And That will summarise the Event in question for convenience.”

“Thank you End Of The Table Manager. Today we are reviewing the case of Patient M. As you all should know, Patient M died during a routine procedure in the General Hospital last month, on the third of February 2020. The cause of death was hypoxia following a series of failed intubations after going into bronchospasm during an elective bronchoscopic examination. The aim of this Serious Event Review is not to lay blame to any one individual, but to look at ways to improve diagnosis and avoid unnecessary risks, whilst delivering affordable and efficient treatment.”

“Thank you Manager Of This And That. So, next… Ah! Dr Cumen, do come in.”

The doctor, rolling down her sleeves whilst simultaneously swiping away notifications on her iPhone, had backed through the door into the board room.

“We’re glad you could make it. If you could just get off your phone and take a seat please.”

“It’s Alex, please. I prefer everyone, including patients, to use my first name. My apologies for being late, I was with a patient’s relatives and needed to give them the time to air their concerns.”

Dr Cumen took her seat and swiped away the last notification on her phone. She threw the phone into her open bag, along with the iSteth clipped to her lanyard.

“And I’m not ‘on my phone’, I’m checking Bleepr as I received a fair few bleeps whilst with that family.”

“Bleepr is supposed to be on your Google Glasses now, Alex.” Manager Of Wearable Communications chipped in.

“Checking your phone for bleeps looks unprofessional. On the Glasses, you can just pull it up, invisible to the patient, in your eyeline. Oh, and we streamed the start of the meeting to you, did you keep up?”

Alex had never used her Google Glasses. They had gone missing when her office was turned into a ‘power station’ with multiple screens for juniors and nurses to access the eHealth central systems (or IT as Alex called it). Not that she would have used the interactive, intelligent specs anyway. When they had been introduced across the trust the year before, everyone had turned to robots overnight. Dr Cumen chose to look her patients in the eyes with both of hers, not with one behind an invisible one-way display of information. She decided not to bring this up in the meeting. It wasn’t worth it. Whilst the End Of The Table Manager presumed Alex had been talking with relatives in her office (obviously unaware that the doctors no longer had any private spaces within the hospital), in actual fact Dr Cumen had been forced to use the ward’s tiny kitchen as a ‘private area’ to speak with the family that day as there were Day Attenders in both the relatives’ room and the day room.

“You’re just in time, Alex. In case you’re Bleepr’d away, let’s start with your description of events. Please run us through the clinical aspects of the case.”

“Ok, yes. As we know, Mrs M died following complications during a bronchoscopy, which was investigating a suspicious mass in her right lung. I saw Mrs M in clinic because she had been losing a lot of weight recently. A chest x-ray revealed a suspicious shadow on her right lung, near the mediastinum. Further imaging was inconclusive so I arranged for a bronchoscope to investigate further and possible reach a tissue diagnosis, during which Mrs M tragically went into bronchospasm and had a number of failed intubations, ultimately leading to her death from hypoxia.”

“In the time I was granted to prepare for this SER, I’ve reviewed her past notes, and the extra information available from her clinic visits. As you’ll see from your briefing reports, a post mortem examination revealed the mass in question to be old lung damage from a tuberculosis abscess which Mrs M had suffered as a child. This was buried in her old paper notes but had for some reason not been coded into her electronic files.”

“Something that isn’t in your briefings, is what I think was the root cause of Mrs M’s weight loss. Again, in the time granted to me to prepare for this review, I discovered that on her visit to my clinic, a medical student had taken it upon themselves to do a mini-mental state examination, or MMSE, with Mrs M. I’d like to think they were being thoughtful and diligent. Or perhaps they just needed it signing off. Either way, Mrs M’s score was 12/30. This could indicate a significant cognitive impairment. I took the time to phone Mrs M’s neighbours, as she has no family around, who have said she had seemed quite forgetful over the past few months.”

“I think on reflection that Mrs M actually had quite significant dementia that hadn’t been picked up on, and had probably been forgetting to eat, hence her weight loss.”

“I knew also that she had asthma, and was prescribed the appropriate inhalers, but she may well have not been remembering to use them. With the iSteth now in use, we don’t even get to hear the chest unless the computer tells us it’s significantly abnormal. Do we have evidence for how well it picks up subtleties? Whether her asthma played a part in the bronchoscopy complications, I’m not sure. Although it was a test Mrs M never needed in the first place.”

“In my opinion, if I had had more time with my patient in the first place, I may have got more of a sense of the real problems facing Mrs M, and could have avoided this whole situation. I was speaking to the clinic receptionist recently who had said she remembered Mrs M’s outfit was quite odd before she changed into the gown before clinic. Like she’d forgotten how to dress properly.”

“These are the subtleties that experienced doctors pick up on, that we sense, if we are graced with enough time. The additional clues from clinic staff and that medical students can sometimes add fuel this gut instinct. There’s a limit to how efficient you can make a clinic before it impacts upon the fundamental elements of a doctor’s role.”

Targets for outpatient clinic consultation length were five minutes per patient. A number of measures had been introduced in recent years to increase the efficiency of patient turnover in clinics. Manager of Targets and Goals, who had remained quiet so far in this meeting, was particularly proud of the latest measure to improve efficiency in the outpatient department. It was now policy for patients to change into hospital gowns prior to the consultation, therefore saving the need to get undressed and redressed for examinations. Four audits had shown it shaved a whole minute from consultations. Thirty seconds at the start and again at the end. Manager of Targets and Goals was very pleased with this. The iSteth had been a huge investment for the trust but had sprung them into the realms of being Leading Innovators in Health.

“Is there anything you think might have helped you in this situation, Alex? It’s about time we brought in a new innovation to the outpatient department.”

“Well, I doubt you’re going to grant me more time with my patients, are you? I teach my medical students about experience and gut instinct, but I find myself utilising it less and less these days.”

“I’m not sure I follow, Alex”, the End Of The Table Manager interjected, “we’ve invested heavily in the guideline and pathway apps on the Intranet, and the clinical decision aids which have proved so popular.”

“But that’s where you’ll never understand. A good doctor is more than the sum of their resources. Over time, some skills become so engrained that they function on the subconscious level. You can’t substitute that.”

“Ah!” (This from the Lead for Incomes and Outcomes), “actually maybe we can. At a conference in Cupertino last week, I trialled a device that could second guess gut instinct. Attached to the  oatient’s wrist, it measured basic observations such as heart rate and temperature, as well as monitoring weight, daily activity, sleep and diet if they have it at home with them. Now I know there are commercial products that do his already, but this one excels as it combines this data and syncs with your phone to analyse it alongside Internet browsing history, TV programmes watched and eReader articles read. It can incorporate the wearer’s medical history to give an overall picture of health and suggestion of likely differentials when specific symptoms are charted on the synchronised app that accompanies the device.”

The table were impressed. End Of The Table Manager made the kind of noises she so often made when she was ready to make a hefty impulse purchase.

Alex sighed. Experience told her there was little point in arguing this, as if preventing the ‘next big thing’ was at all possible.

“What’s the device called?”

“Funnily enough Alex, it’s being marketed as ‘The Clinical iCumen’.”

Alex left the meeting deflated and defeated, despite the point of an SER not to be laying blame or fault on any individual. As she walked back to the ward, to catch up on what was missed whilst in the meeting, her resignation letter and early retirement plans were already swirling into formation in her head.

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