Gordon Caldwell | Patient Safety, Humanity in Medicine, and a photo that went viral.

Lets begin with the story of that photograph.

I was getting increasingly frustrated on ward rounds, battling with piles of nursing paperwork and trying to find simple things like the patient’s weight and the most recent blood glucose.  I asked the charge nurse on our ward to give me one copy of every piece of paper that the nurses had to fill in in order to admit a patient to a general medical ward. We chose, as our example, a diabetic patient who would need intravenous antibiotics. Kirsteen gave me all those sheets of paper. I was thinking of sticking them around the wall but then decided I’d just lay them on the floor in my office. Lindsay, my secretary, came in and said- “what on earth are you doing?” so, I told her and she said, “well, why don’t you just lie down on the floor and I’ll take your photo to give some sense of perspective to it”. So that’s how the photograph came about.

DMacA: It really is a remarkable photograph. We’ve seen photographs of people with books piled high of guidelines and we can see how difficult it is sometimes just to navigate the Health Service because of the bureaucracy. But, let’s take you back a little bit. Tell us about your own personal career.

GC: I trained in Oxford for three years, then went to King’s College in London, worked there for six months and then down to Brighton for a few years. Up to Edinburgh where I studied Endocrinology, back to the Postgraduate Medical School in London to do some diabetes research, a Senior Registrar job in Newcastle, and then down to Worthing where I became a consultant in 1993. I worked there until to the end of 2017, and then spent four years working on the west coast of Scotland in Oban as a consultant General Physician.

DMacA: What really interests me is your work on the ‘human side of medicine’, because this is a particular interest of yours. Tell me a little bit about that.

GC: The curriculum at King’s College in London was very much based on the Osler principles, and going back to Boerhaave, that learning and teaching come from being with the patient, seeing the patient, understanding the patient, and connecting with the patient, and that was what drove my learning. It was because I’d met the patient that I wanted to understand how to interview and examine the patient, how to make a diagnosis and to treat and manage the patient. So, I think learning comes from that. And to me, the essential component of being a doctor is this professional human relationship. We have to know the person if we’re going to treat the person.  One of the things I have tried to teach every student and every junior doctor, is find out who the person is before you start treating them as a patient. Unless a person was unconscious in A&E, I always started by asking… remind me how old you are, what is or was your job, what interests you, and what you do you enjoy these days. And that creates a very strong connection very quickly from which I can then remember the patient. Often I’d use that information as a memory hook for the whole of the case. But, it’s more than a memory hook, it creates the connection as well.

DMacA:  I heard you speak about a patient on one occasion, and I was struck by your kindness. You had asked a dying patient what they would like, and they said they would like an ice cream.

GC: A middle-aged man had been admitted with advanced pancreatic cancer and, when I came to the bedside it looked like he was going to die fairly imminently. I felt rather useless and, at the end of the consultation, because the nurse had addressed his pain very well and he looked comfortable,  I asked- “is there anything we could do for you” and, he said “I’d really like an ice cream”. And, that student nurse went to the hospital shop in her break and bought him an ice cream, brought it back to him. He ate the ice cream after his lunch and then he died. And I just had to commend that nurse to the sister for her humanity. Seeing what the man wanted, doing her extra little bit. When he died he’d just had the thing that he wanted. That struck me as the core of medicine and nursing. We’ve got all that science, and all that ability to relieve the pain, to make the diagnosis, do all the scans and biopsies, but there’s still humanity.

DMacA: It also struck me how you’ve joined up those different parts- from the humanity, to the technology, to the organization. I think you described it as ‘paying attention to the ordinary’.

GC: Doctors tend not to think very much about ward rounds because they’re so ordinary. And yet the reputation of international companies is based on what they regard as ordinary, and doing their ordinary work very well. The reputation of Volkswagen was built on the Beetle and the Golf and not on top performing sports cars. So, I wanted to concentrate on ward rounds and the various components of ward rounds because they’re so ordinary that people generally hadn’t even thought about them. How do we go about organizing them, what’s the process, how do we maintain safety, teaching, humanity, within the context of that very busy pressured environment.

DMacA: Another of your interests is in quality and safety. Tell us your thoughts on quality and safety and how we can integrate that more into healthcare.

GC: Lord Darzi had been talking about quality and safety, and as I read about it, I didn’t quite understand what it meant at the point of care. And then I became increasingly aware of the mistakes that were made within my team. For example, I can remember that on one occasion within a two week period, we had two patients who were given intravenous Co-Amoxiclav, both known to be allergic to penicillin, and both nearly died of anaphylactic shock. And, they were both wearing red wristbands. What was happening that things were going wrong? And that’s when I started reading about quality and safety, particularly in the airline industry, and how Safety is No Accident. I wasn’t really doing any active patient safety checking. There were all these different initiatives like, have we identified whether somebody is at ‘falls risk’, is the prescription chart legible, have they had their VTE assessment. There were many aspects where I thought would be better if we were active and went through a standard process with every patient. That particularly came to light after I allowed a Foundation Year One doctor to lead a ward round when she saw 25 patients in the morning. At the end we asked what she thought of it. We had, of course, been supporting her and helping her all the way, and she said ‘she didn’t know if we’d done everything’.

The following Wednesday we decided to discuss what we think “doing everything for every patient” is. Issues like- have you checked they’ve got a canula, checked they’ve got a catheter, as well as have you checked they’ve got the correct diagnosis. And by Friday we had our first checklist. We then asked the medical student to watch and see if we’d completed them. And, that started what I call, ‘Active Patient Safety Checking’. It can be really quick – are you eating and drinking, have you been walking around, have you got a canula, have you got a catheter, have we checked your VTE prophylaxis, have you got any wounds and dressings. But, by making it into a standard process, which is multi-disciplinary, you could then come away from the patient reassured that, although we may not have made all the right decisions, we’d made all the decisions we had to, we’d looked at everything, and we did a thorough job. That was bringing quality and safety right down to the patient’s bedside. The patient would feel secure, we’d feel secure, and we’d know we’d done a good job and completed everything.

DMacA: This creates an interesting challenge for medicine because, consultants like an individual approach but a checklist means a generalized approach. How can we integrate individualism with the generalist checklist?

GC: I realized that it’s not a checklist, it’s a process. If you’ve got an important process then you usually check up on it. If, for example, you’re getting ready to go on holiday, you check you’ve got your passport, your credit card, your telephone, and you’ve got all your clothes. It’s a natural thing to check the process.

I didn’t want to influence people’s diagnostic thinking and their conclusions about treatment, because we all know every cardiologist will choose a different medication for atrial fibrillation and have a different attitude to anticoagulation. I wasn’t going to try and influence that. I just wanted to make sure that whatever medication they decided upon was written up and legible, and everybody knew who had written the prescription, and it was all being administered. And that all their good work wasn’t undone by somebody forgetting, for example, to take the canula out of the arm so they got sepsis and bacterial endocarditis.

The change was to bring active safety thinking into the process, rather than what I used to do on my ward round: Turn up at the bedside, look at the diagnosis, think we’d covered everything, and go away. In the first few weeks we were doing this, we found that we were appalling at checking for cannulas, really bad at checking for urinary catheters, very bad at DNA CPR decisions, care decisions. While we thought we were good at it, we discovered that we weren’t because we were following the process and the medical student pointed out the things we hadn’t done. I remember that we decided we must communicate with the nurse after we’d seen the patients.  My Registrar, Dr Imo Umo, would say “Dr Caldwell, you haven’t spoken to the nurse yet, we’ve got to go and find the nurse” And, we’d end up walking all around the ward to find the nurse.

DMacA: I was very interested in the way you gave responsibility for that ward round to the FY1 doctor, and how you included the medical student. Finally, what is your message for medical students today?

GC: The first thing is get to know the person. Get to know the person right at the beginning, before you make them into a patient. Get that human connection. Students who came on our team loved being on the team because they had a role, they had a voice and a responsibility. I’d love to see my colleagues using this approach so that the medical student is viewed as an essential component of the team. I always found it much better because if a medical student is asked to speak, they’ll ask questions, and then we can talk about the science of medicine.

I would say to them- medicine’s still a great career as long as we’re allowed to practise medicine.

DMacA: Thank you very much. It’s been an absolute pleasure talking to you and thank you for sharing your wisdom and experience, and some that beautiful ‘human side of medicine” Thank you very much indeed