The Essential Handbook for GP Training & Education

let’s do a little reading…

Transforming practice with RDM-p

Ramesh MehayTPD (Bradford)

Transformative change

Alters the culture of the institution by changing underlying assumptions and overt institutional behaviors, processes, and structures.•It is deep and pervasive, affecting the whole institution•It is intentional•It occurs over time

Aims & Objectives

• An overview of RDMp and SKIPE • Really understand what each domain means.• Help you understand and categorise evidential statements• Help you apply the approach to different contexts• Hook you in! This stuff will change you!

Why bother with RDM-p?

• Far too often we think of decisions as ok or not okay• But decision making is a process, not an event.• Far too we look at the outcome rather than the process• RDMp starts with the process• And therefore helps you make decisions better.

Apophenia

seeing meaningful patterns or connections in random or meaningless data.

We make premature judgements from just a few bits of information

• “Perhaps she’s not managing with being a new mum”• “He’s clearly lazy and needs to pull his finger out”• “She’s a bit thick and needs to read a bit more”• “It’s because of his language and culture”

YOU MAY BE BARKING UP THE WRONG TREE!

But System 1 thinking can be wrong!What’s this?

To make decisions BETTER

We need to slow down!

Please find a piece of paper and a pen

• A list of words follows• Look at them once, do not re-read them• When you have read the list close your eyes

FlangeRoute master

LaggardSausages

AutomatonApproachAntichristResearchSlipperHaggleFridge

LocomotiveBracket

ConfusedTelesalesProfessor

Stool pigeonHale

BanquetIrrelevance

Write down as many words as you can remember

FlangeRoutemasterLaggardSausagesAutomatonApproachAntichristResearchSlipperHaggleFridgeLocomotiveBracketConfusedTelesalesProfessorStool pigeonHaleBanquetIrrelevance

AA

BB

CC

DD

EE

How many wordsthat you remembered are in each group?

How many wordsthat you remembered are in each group?

• How many words did you remember?• How many did not exactly match the words on the list?• What does all of this mean for us?

We jump to conclusions and rush to ‘fix’ the problem – which fails to do the trick!

Click centre to play video

And that means…

We need to gather comprehensive ‘all rounded’ information:•From the trainee•From things you already know•From talking to others: colleagues, trainers, other docs and patients (+other stakeholders).

Dual Process theory

Daniel KahnemanEconomics

2002

System 1 = intuitive; System 2 = analytic

System 1 thinking (intuitive) – what’s the diagnosis?

System 1 thinking – Diagnosis & Treatment

DiagnosisDiagnosis RxRx

System 2 thinking (analytic)

• 85 year old with a raised cholesterol and who is hypertensive but prefers not to go on statins. She’d like to know what you think though.

• What next?

With the trainee in difficulty

• We often go for system 1 thinking• We should be going for system 2 thinking

STOP, BLINK & THINK

Dwivedi G, et al. BMJ 2006; 332: 406

• Mrs Patel; R chest pain.• 28 years old, 7 month old baby.• Pain started 2 months ago, well localised over the R chest

wall with no radiation. Precipitated by pushing daughter in pushchair

• Pain not exacerbated by deep inspiration, coughing or twisting; no dyspnoea, palpitations or dizziness.

• Previous GP consultation = musculoskeletal pain.• PMH: Type 2 diabetes 3 years, well controlled on oral

medication (HbA1c 7.5%); hypothryoidism, l-throxine 25micrograms daily

• BMI 34.6

Dwivedi G, et al. BMJ 2006; 332: 406

• Mr Patel; R chest pain.• 65 years old • Pain started 2 months ago, well localised over the R chest

wall with no radiation. Precipitated by pushing granddaughter in pushchair

• Pain not exacerbated by deep inspiration, coughing or twisting; no dyspnoea, palpitations or dizziness.

• Previous GP consultation = musculoskeletal pain.• PMH: Type 2 diabetes 3 years, well controlled on oral

medication (HbA1c 7.5%); hypothryoidism, l-throxine 25micrograms daily

• BMI 34.6

Dwivedi G, et al. BMJ 2006; 332: 406

• Mrs Patel; R chest pain.• 28 years old, 7 month old baby.• Pain started 2 months ago, well localised over the R chest

wall with no radiation. Precipitated by pushing daughter in pushchair

• Pain not exacerbated by deep inspiration, coughing or twisting; no dyspnoea, palpitations or dizziness.

• Previous GP consultation = musculoskeletal pain.• PMH: Type 2 diabetes 3 years, well controlled on oral

medication (HbA1c 7.5%); hypothryoidism, l-throxine 25micrograms daily

• BMI 34.6

Who knows the story of Noah in the Bible?

Imagine you are working as a doctor in a remote village. It’s the Imagine you are working as a doctor in a remote village. It’s the weekend. There are no other health care professionals around. weekend. There are no other health care professionals around. But you do have a new piece of technology called THE But you do have a new piece of technology called THE MARVELTRONMARVELTRON

• The MARVELTRON will save the life of any patient you are treating.

• But you have to answer correctly the question the MARVELTRON asks of the attending doctor before it works its magic.

• A young child is brought to you. She is seriously ill and will die imminently.

• You switch on the MARVELTRON and await the question.• You must write down your answer immediately the question

is asked, or the child will die.• You will be blamed for the patient’s death only if you do not

write down an answer. No blame will be attached to you if you get the answer wrong.

• ARE YOU READY? • Have you got paper and something to write with?

• According to the Bible, how many giraffes did Noah take into the Ark?

Answer quicklyWrite it down

The child is dying.

How many giraffes?How many giraffes?

• 00• 11• 22• 33• 44• 55• 66• 77• More than 7More than 7

The correct answerThe correct answer

• Of every clean beast thou shalt take to thee by sevens, the male and his female: and of beasts that are not clean by two, the male and his female. Of fowls also of the air by sevens, the male and the female; to keep seed alive upon the face of all the earth.

Genesis. Ch 7• Whatsoever parteth the hoof, and is cloven-footed, and cheweth

the cud, among the beasts, that shall ye eat. Leviticus Ch

11

• Where did you get the information from to make the decision about Noah and the giraffes?

• If you had had time, what would you have done to make sure you had the right answer?

So what am I trying to say?

• We need to be careful of jumping to conclusions or relying on our ‘hunches’

• With familiar situations, just stop to pause and think for a moment to ensure you’ve considered alternatives.

• With the unfamiliar - check things out properly. Data gather comprehensively and triangulate pieces of evidence against other pieces of evidence. Look for themes

And RDM-p helps you do just that.

• It represents all aspects of our work• Comprehensive collection of data• Triangulates different bits of evidence• Helps you make sense of that data• Provides a framework with which to explore things with the

trainee.