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As I said yesterday, I’m doing a story skills workshop so stories is what you’re going to get from me at the moment. Today I wanted to share a story about a moment that really shaped my professional life. It confronted me in multiple ways, and was a life defining moment that I hope I never have to repeat.

I made the front page of our city newspaper once. Not that they used my name. I was “The nervous novice” they referred to.

I wasn’t really a nervous novice. I had been working at that hospital for a few years and was in a senior role within the department. That was the reason I was called upon to provide cover when the long-term (like 25 years long term) oncology pharmacist took long service leave. Nobody else would do it.

She taught me the processes and how to make sure the kids got the right chemo at the right time. The diary, the clunky old computer program (basically a glorified calculator), the aseptic suite. Over weeks or months I was able to demonstrate my proficiency and was trusted to keep things tickling while she went on holidays.

I came to realise what I’m sure many people realise when they take over a job from someone who has been working in isolation- things that make sense to them don’t necessarily make sense to others. They keep a lot of important information in their head, resulting in ambiguity for the poor sucker trying to keep things ticking over as usual (aka me). There were processes, sure, but they were designed in a way to make her indispensable. This wasn’t exactly sustainable or safe.

I must have done a good enough job because a few months later I was once again called upon to provide cover when she retired. I was entrusted to provide support for her newly inducted replacement, who incidentally had even less experience in oncology than I did.

I did as requested and kept things ticking. Figuring things out as I went along. Until I found something that I couldn’t figure out. There was an irreconcilable difference between the computer generated batch sheet and the computer generated label for one of the chemotherapy agents. This meant we either prepared the correct amount of drug with the wrong label, or the correct label on an incorrect amount of drug. This is not good for any drug. It’s especially not good for a chemotherapy drug.

I didn’t know what to do with this problem. I first took it to my colleague who had been in her role for a matter of weeks. She wasn’t sure. I then went to my manager. I explained that either I had lost my ability to do basic maths or there was a systematic error occurring with this chemo drug. He confirmed that my understanding of ratios was still correct. Oh shit. What did this mean?

It meant a full enquiry of every time we had ever prepared that drug. It meant a full audit of all of our processes and documentation relating to chemotherapy. It meant long days and evenings working in an area that I was only supposed to be providing short term cover to. It meant a bunch of people pissed off that we had brought this error into the spotlight and created so much work. It meant a news story that cast aside the error as a serendipitous discovery made by a nervous novice.

It meant I never viewed the term ‘indispensable’ the same way in healthcare again, regardless of how much I enjoyed reading Linchpin by Seth Godin.

All That Glitters

Over the past few weeks I’ve been participating in a story skills online workshop, and I’ve got to say, it’s pretty amazing. I’m learning so much. One of the things that’s surprised me, was the power of storytelling in our day to day lives. So I thought I’d do the only appropriate thing to do about a topic like that. I wrote a story about it, obviously. I’m not saying I’m very good at it, but I’m enjoying the practice.

At the beginning of the year I was talking with my daughter about what she wanted for the year ahead. Her reply, “to be in a performance”. OK, that sounds pretty achievable, I thought. I looked up dance schools and was pleased to find a good one within walking distance. After initial disappointment of no availability, she was able to start dance lessons mid-way through March. In three weeks time she has her big end of year concert. The excitement is building. They have learned all the choreography. On Saturday she was provided with her costume in all its glittery glory.

Seeing her with her blue tutu prompted me to get online to get our tickets. I had left it too late to get prime view seats I was sure. What I hadn’t expected was for them to be completely sold out. My heart sank. Her first big concert and we couldn’t even get one lousy ticket. I only wanted two! Why had I left it so late? Why do I always leave things to the last minute? My mum would never be in this position. My sister would never be in this position. Why did I put us in this position? I couldn’t hide my disappointment. I couldn’t hold back my tears. When my daughter asked what was wrong I told her I’d stuffed up. “That’s OK, I’ll have other concerts” she said. That helped me refocus, and turn my attention from woe is me to what now.

Previously my instinct would be to get mad. Surely they’d allocate tickets for each kid! Surely they’d communicate this more proactively! Surely they’d make a point of telling first timers! These thoughts did go on in my head, but they didn’t take hold of me like they would have in the past. And sure, I did go back and search through emails to gather evidence, but I kind of knew it would be evidence that I had ignored their communication, not evidence of their transgression. And sure enough, there in the email I received at the end of October announcing tickets were on sale it stated very clearly “tickets will sell out”. In red type and all. I just didn’t interpret this as act now or miss out. In my mind, buying with three weeks to go is planning ahead!

So I didn’t get angry, but I was still upset. An emotionally together person would have got on the phone straight away. But I hate talking on the phone at the best of times, let alone when I know it will end in tears. Disappointment or anger, I wasn’t sure which. I emailed. As I was writing my email I thought, what’s the point? I’m sure I’m not the only one that’s missed out. They’re probably used to getting blasted by angry parents about this, that’s why they have the disclaimer in the email. They’ve probably prepared a standard response they use for everyone. Then my mind shifted. Maybe I could communicate in a way so they actually want to help me? Maybe I could tell them a story.

I mustered up all the story telling skills I’ve acquired so far and started on my story. I tried to engage them by making it clear that I wasn’t like the other angry parents – I was the one at fault and wasn’t blaming them. I tried to make them care about my situation – I was feeling terrible that I had misinterpreted the information and just wanted some way of being there to support my daughter at her first performance, volunteering back stage, whatever. I acknowledged that I had learned my lesson – I would never ignore their spammy emails again (obviously I didn’t say it quite like that).

I didn’t get a reply, but the process did help me to get my head around the situation enough to call them, which I did just now. As I predicted, the conversation started with a fairly standard and guarded response, but she gradually softened throughout the interaction. My name is on the waiting list for the “ticket master”, and I’m on the list for backstage volunteers. The storytelling might not have made any difference to the outcome, but it made a difference to the process. I still feel a bit sad and annoyed with myself, but I don’t feel angry and distracted. So I’ll take that as a win.

 

Girl Interrupted

I’m having one of those weeks where I feel very disrupted. I know I need to take my own advice and be disciplined rather than motivated, but I am resisting it. It’s a combination of things. Workers at the house building our carport makes me distracted. Hot weather making me lazy. Crazy windy weather giving me allergies. I feel discombobulated. But that’s ok. We all have these moments and I’m sure it’ll pass. Quickly though, I hope.

Posy or Perish

It’s a stifling hot day today in Adelaide. 42 degrees in November. The kind of day where you can feel your skin tightening as soon as you walk out the door. To make things worse, it’s windy as hell. My allergies have gone crazy. I’m procrastinating like you wouldn’t believe. This is not a great day.

Needless to say, I didn’t feel like going for a run this morning. And I could tell my daughter wasn’t exactly energetic either. So I made the decision early to drive which gave us some extra time. Time I could spend watering the garden so it at least has a chance of surviving the day.

My daughter came out to help. I noticed the sweet peas and picked one for her. They looked especially beautiful this morning and I knew they wouldn’t stay that way for long. You should pick some for your teacher, I suggested. She agreed. We collected a posy of flowers, wrapped the stems in some alfoil as my mum and grandma would do, and took them with us to school.

I could see the look of pride on my daughter’s face as she approached the teacher’s desk who was already surrounded by a group of children. But she waited patiently. I stood back by the door as I hadn’t said goodbye yet, and have been told off before about escaping too hastily in the past. So I waited. I too was patient.

I got distracted while I was waiting and tuned out for a while but my ears tuned back in when I heard an exclamation “Are they for me? Oh thank you so much”. I looked up and saw the teacher blissfully inhale the heady scent of the sweet peas. “My dad used to grow these in our garden. I used to love smelling these”. It was like she had been momentarily transported back to her childhood and had a sparkle in her eye. My daughter was thrilled. My heart was warmed. Much better than letting them perish in the garden on this hot spring day. That’s the thing about kindness I think. It doesn’t take much effort at all.

Discovery Doesn’t Always Lead to Happiness

I know I’m probably setting up my kids for a lifetime of emotional eating, but sometimes the short term benefits of using food as an incentive are just too good to pass up. Yesterday was one of those days. It was hot in Adelaide. Not as hot as today (a stifling 42 degrees) but still hot.

My son is 5 days short of his second birthday. He still likes to have a long nap, and on school days it always seems to be that they are perfectly timed so he has to be woken for school pickup. This is annoying for everyone involved. He’s understandably grumpy about being woken and put in the car. My daughter is understandable grumpy because he’s grumpy which means she can’t stay and play with her friends. I’m grumpy because they’re both grumpy,and the walk to the car, although not far, is a physical struggle when you’re carrying a squirming two year old and it’s a hot day.

Enter the food bribe incentive. Hot day, perfect for an ice block. This provides my daughter with the momentum she needs to move to the car and be a good example for her brother. It does nothing to help my son, but at least there’s only one grumpy one to deal with now.

Once home, both children head straight to the freezer. We have one of those fridge/freezers where the freezer is at the bottom so there’s no going back now, the door is open and the selection is being made. I get them into a position on the kitchen table to limit sticky spills and let them have at it. No one is grumpy any more.

I watch my son navigate the ice block. A zooper dooper. This treat turns into a lesson in physics for him.

He furrows his brow and experiments with how the ice moves as he squeezes it in the middle. He breaks it in half and moves each of the sections. He realises he doesn’t need the wrapper and displaces the ice chunks into the bowl that I gave him to catch the inevitable drips. He feels the cold of the ice on his hands, and touches other items to compare. Then he spots his cup of water.

In goes the first chunk of ice. The water turns green (this is not some sort of organic fruit juice, no added colours type iceblock). The ice disappears quickly. He looks perplexed. He tentatively drinks this mysterious liquid. He doesn’t enjoy it. He looks at the other chunk of ice in his bowl, as though he’s weighing up his options. Into the water it goes. He has regret and puts his hand in to retrieve it, but it’s too late. The ice chunk has disappeared and he’s left with the green liquid. He is not pleased.

He escapes the chair and makes a bee line for the freezer. He knows where there is more supply. He makes his selection and looks proud. Pink this time. But he’s unable to break through the packaging. He needs scissors. I have the scissors. His grumpiness returns.

Where’s the Neutrino?

Sometime around the 1930s there were all sorts of scientists working on deciphering equations to explain beta decay in radiation. I am not even going to pretend I understand this, it’s not important for the story. What is important is that one of these scientists came up with a theory about why noone was able to come up with an equation that held up. He suggested that some kind of particle that was neutrally charged must exost and be influencing things. And he got laughed at. Dismissed. It wasn’t until years later (sometime in the mid 1950s I think) that someone else discovered this particle and called it the Neutrino.

Oftentimes when we’re in the midst of out problems we don’t recognise the invisible forces that are holding us back from making progress. To do so requires us to have an overarching view of the big picture, remain somewhat detached from what is known and open to possibility, and make ourselves vulnerable as we risk looking foolish to others.

Over the 16ish years I’ve been practicing as a pharmacist, issues relating to transitions of care, preventable hospitalisations and poor adherence have persisted throughout. In spite of the significant level of investment that has been made into hospital pharmacy services and community based services such as the HMR and DMMR programs, the stats have remained persistently high. If this were a drug trial it wouldn’t be looking all that promising. In their recent report, AIHW estimate that around 7% of hospital admissions were potentially preventable, accounting for around 10% of hospital bed days.

It’s clearly not acceptable that there were 748,000 potentially preventable hospitalisations in 2017-18. I think this should be seen as an indictment of healthcare policy, not necessarily of the individual providers. Of course we need to improve and we need to strengthen the quality and safety of the community based care sector. But we need to achieve systemic improvements supported by effective policy. Short term policy and chopping and changing the structure of the primary care sector has failed us for too long.

One likely reaction to this sort of data is that we obviously need more resources and services in order to meet these needs. In the case of pharmacists, we need post discharge HMRs, pharmacists in GP practices, pharmacists in RACFs, more hospital pharmacists providing outreach, pharmacists anywhere anyone will pay for them. But I want to be somewhat controversial, zoom out, and take a different viewpoint. I don’t believe the best way to fix a fragmented healthcare system is to throw even more people, services and referral pathways into the mix. We need to rethink the overall strategy. Maybe there’s something else that’s holding us back – the neutrino that we can’t see.

I believe the neutrino relates to undervaluing generalist care providers. My firm belief is that we need to start investing in strategies that strengthen the community based workforce. Not through increased numbers, but by valuing and respecting the workforce that we already have and optimising their capability. For too long community based care providers have been considered the poor cousin of their hospital counterparts. The after thought for funding models. If we want to make improvements in things like preventable hospitalisations it needs to start with recognising that our health system will only ever be as strong as our community based sector. They deserve our respect. They deserve to be prioritised. They deserve financial investment.

For my entire career thus far we have been talking about the same issues and making limited improvements. Maybe there’s something else going on here that’s holding us back, and maybe that thing is a culture that doesn’t value community based care and generalist providers. Maybe we need to stop putting culture change in the ‘too hard basket’ and start taking action to change it. Because it needs to change. I believe that improving the connection between acute and primary care providers is a good place to start.

Community Pharmacy and Cancer

I know that I bang on a bit about the value of generalists in a specialised setting, but I’m not about to stop. I’ve devoted at least half of my career to it, it’s the basis of my PhD and I see opportunities related to it all the time. Many of those opportunities relate to cancer care, and one in particular relates to cancer screening programs.

I must be honest and say that I never realised how expensive many cancer screening programs are. Nor did I appreciate the costs (both financial and to the individual patient) of over diagnosis and treatment. This means that even though there are effective screening methods for some cancer, they are not suitable to roll out across the entire population.

One of those relates to lung cancer. There is a screening method available but it would cost more than $100k for each QALY gained, which is simply not affordable. But it could be affordable if the program targeted those at higher risk, such as smokers.

Targeting these people can be easier said than done though. They might not go to their GP. Public advertising campaigns are expensive and not very effective these days with so much competing for your attention. So my question is, why aren’t community pharmacists pushing to be involved in this? Why aren’t community pharmacists jumping at the opportunity to be involved in this important public health measure of cancer screening? Why wasn’t there a PSA representative at COSA flying the flag for pharmacists in the community setting?

I think there are two main reasons. The cynical reason is that it’s not a service that is transactional (I.e. revenue raising). The other reason is that I think community pharmacy avoids cancer. They consider it to be within the domain of specialists and don’t recognise how they can add value.

Community pharmacists, any pharmacists, can add value to cancer care and I think it’s time we started recognising that. It’s a leading cause of death and affects the lives of many people and their families. They need primary care and generalist medication management services as much as anyone else with a chronic condition does.

To MDT or not

This follows on from my previous post, reflecting on the COSA ASM.

Now, I haven’t been to heaps of conferences. But of those I have attended, I’ve noticed a marked difference between the ones that are multidisciplinary compared to the pharmacy ones. The main difference is the focus on the patients, not the profession. Cancer does this really well, and so does primary care. Consumer focus can be seen throughout. They are even involved as conference participants. It changes the dynamic considerably, and I believe it is for the better.

Pharmacy conferences are a great opportunity to catch up with colleagues, but I don’t find the learning as valuable as multidisciplinary meetings. Maybe because the audience is easier – more homogeneous. There’s expectation that the audience will be encouraging and less of a need to defend assertions as when other types of professionals are in the room. I don’t think this is unique to pharmacy, I’m sure it’s the same with other disciplines. The result is that single profession conferences have a tendency to become a mutual gratification society. An echo echo chamber of positivity and professional tribalism. It’s not that this is a bad thing per se, I understand that there is a need for it. I might even be willing to pay for this every now and then. The trouble for me is the cost.

The cost is both financial and opportunity cost. I know there are some people who do the conference circuits throughout the year, traveling here there and everywhere, but I couldn’t do that even if I wanted to. And I’m sure that I’m not the only one. So I have to be selective. Sometimes my selection will be based upon location. I mean, not solely on location, I’m not about to go to the real estate conference just because it’s at the convention centre. But at the moment, conferences in Adelaide are pretty appealing as childcare is taken care of and I don’t have to pay for travel and accommodation. This might sound an awfully unromantic method for choosing, but it’s the reality. Even if I could afford it financially I couldn’t manage an international conference at the moment.

What perplexes me though, annoys me even, is that pharmacy conferences always seem to be more expensive than the multidisciplinary meetings. This doesn’t make sense to me. I mean, I would get it if they refused to accept drug company sponsorship and were fully self funded, but as far as I’m aware this isn’t the case. I think this is a problem. To ignore it risks significant leakage of people to more affordable multidisciplinary meetings.

Who are you?

This week I had the pleasure to attend the COSA ASM. Honestly, I don’t really like conferences all that much. I find them exhausting. Networking makes me incredibly uncomfortable. I can’t pay attention and listen to back to back talks all day. Food in bain marie’s scares me. But despite this it was overall a very worthwhile experience.

I think I’ll write a few posts reflecting on different aspects of it. Today I’m thinking about identity.

While I may loathe networking, I love people watching. And there is people watching a plenty at a conference. There are a number of typical archetypes to be found. This provides me with entertainment, and it also prompts me to think about where I fit. What do I want my identity to be?

Truthfully, I don’t know. While I admire those who have deep expert knowledge, the top of their specific field, I don’t think that’s for me. I struggle to stay focused on one thing. Similarly, I find the passion of the clinical leaders implementing services that are designed to better meet the needs of their patients inspirational. But I don’t know if that’s for me either, I’m not primarily a clinician at heart, I’m more about systems. I am compelled by the no bullshit, big picture policy makers. That is the sort of work that has the most pulling power for me. But if you pursue that path you have to accept that you’ll have to work with a bunch of faker empty rhetoric types. I have a feeling the fakers have the numbers too. I’m not sure that’s a good fit for me either.

So I don’t know where I fit, and that’s ok. I don’t have a career path I’m working on. Instead I’m focusing on attributes. Skill acquisition and experience. What do I enjoy working on? How can I get better? How can I find interesting opportunities to challenge myself? Work on being me, and that’s enough for now.

Adverse Life Reactions

I heard something yesterday that I thought was a great way of framing the need to take control of yourself in situations rather than get caught up in the moment.

If a doctor (or other suitably skilled healthcare professional) tells you that you have responded to a medicine you would probably perceive that as a positive thing. Progress toward your goal. Would you still feel that way if they told you you have reacted to a medicine? Unlikely.

We have a choice to respond to situations and circumstances or react. Reacting is natural and emotional and may even feel good in the moment, but does it serve your underlying purpose? Responding can be a challenge and can feel uncomfortable, but it’s likely that it will serve you much better in the long run.