Sociology and AMS

I have a love hate relationship with sociology. The hate part relates to Sociologists tending to be very academic, which I find mentally exhausting. They use big, jargonistic words. There is always some theory that you’ve never heard of before to consider. It’s pretty much impossible to have a straightforward conversation about a topic, it’s always deep and I’m often left feeling a bit simple because I don’t always pick up on the concepts or understand what they’re talking about. But I find that it’s worth enduring this because whatever the topic under discussion, I always leave the conversation with something to think about. This is the very reason that I sought out having a Sociologist as my PhD supervisor – to make sure I don’t accept the superficial but explore the broader context and interplay between varying constructs.

So seeing that the latest Purple Pen Podcast episode was Sociology and Antimicrobial Resistance with Prof Alex Broom made me very curious. And listening to it left me with a few points to ponder and consider more deeply that I thought I would write down to help me think them through. For me the learnings aren’t necessarily to do with antimicrobials, but that’s the thing about discussions with Sociologists, they take your mind down different rabbit holes that are fun to explore. I’m going to share my thoughts as they were presented in the podcast and provoked my thinking, so it’s a bit disjointed.

What we often miss in health environments is how who we are really shapes our illness and what we experience

This has been one of my biggest learnings from my PhD and interviews with people managing cancer and coexisting chronic conditions. I went into it thinking about medication management mechanistically. That people are bound to experience issues with their medicines when they’re going through cancer treatment because they get presented with a greater workload relating to managing their health, but have reduced capacity because of the effects of cancer and it’s treatment. What I learned was how much someone’s sense of identity and life experiences shapes their perception of this health experience. If someone has lived a life where they have lost a child and a husband and experienced a prolonged period of deep grief, then getting diagnosed with bowel cancer isn’t necessarily seen as all that bad. If someone has suffered through the onset of MS that completely disrupted their career and life plans and set them on a path of self-management, then their approach to taking an active role in their breast cancer treatment is quite different from someone who only ever goes to the GP when they get sick. Health experiences are way more complex than health literacy.

Optimisation and judiciousness not just being about accuracy but actually being about responsibility. Then what we do becomes a moral question.

This was discussed in the context of how antimicrobial stewardship programs aren’t just about getting the right antimicrobial to the right patient, but about society more broadly. There are two different approaches to AMS, or what I would consider marketing strategies. The typical one that is seen is AMS correcting misuse of antimicrobials, which is a fairly negative construct where prescribers feel constrained or disciplined and pharmacists (or others) get a bit stuck in the middle. Compare this to presenting AMS as an opportunity for care providers to act in the collective best interests of both the patient in front of them, and future generations. This allows people to demonstrate their professional commitment by taking action to contribute to the mission and do something positive. I think this quite obviously applies to all QUM; policing drug use compared to optimising medication outcomes for individuals and society as a whole.

if we approach AMS as a problem of behaviour management we risk missing the broader super structures that shape how people behave

This was discussed in the context of challenging the ideology of changing individual behaviour. Again, so relevant to broader medication management, in particular medication taking behaviour. Just the terms compliance and adherence demonstrate the emphasis that we place on individual behaviour. Yet, we’re clearly failing to make much progress as rates of non-adherence have sat pretty consistently at around 50% for the past fifty years or so. We are not skilled at shaping medication taking behaviour, and  sometimes I wonder if as a profession we even really care. I mean, a hell of a lot more research has been conducted relating to quantifying the problem rather than understanding why it occurs. I believe that comes down to scientific disciplines like Pharmacy over-valuing quantitative and under-valuing qualitative research. The flow on from this is that most of the strategies we’ve implemented to address these issues focus on unintentional non-adherence, which is only about one third of the problem. But it’s a bit hard to address intentional non-adherence when you don’t understand it I guess. Much easier to ignore it and hope no one who funds services notices it’s still a big problem.

misalignment of the values of the institution with the necessary values that would drive AMS

That might not be a direct quote, but it’s what is generally spoken about at the 8’55 mark. It’s discussed within the context of AMS being seen as a requirement from a governance perspective, so programs are put in place, stewards employed etc. But unless such programs are supported by the institution getting behind the approach and demonstrating that it is something they truly value and see as a way of achieving better outcomes it’s pretty much a given that success will be limited. AMS is then seen as a tick box exercise for achieving accreditation. People don’t take personal responsibility to contribute to the mission which prevents the desired goal from being achieved in a meaningful way. Again, this relates to so many aspects of pharmacy practice, and I can think of multiple examples of where I have been placed in this type of position where I’ve been tasked with implementing something but when it came down to it the support just wasn’t there. And being in that position suuuuuucks.

culture articulates all the structures we need to work with in order to implement in real world settings

How many times have you read a journal article about an implementation project where the biggest barriers were noted to be cultural? I bet you most of them offer more education and training as a solution to overcoming this. Do you think that will work? No, me neither.

not about correction but motivating people that what they are doing is making a difference

This was in response to a question about how do you actually create an environment where doing the right thing becomes accepted, normalised behaviour. He talked about it coming down to feedback and reward systems that enable tracking without creating a sense of winners and losers. That cross-comparisons can be useful, but they are not always used in a positive, constructive way. When you think about this from a social justice perspective, reasons people don’t feel motivated are that they’re not understood, or they feel like their environment isn’t conducive to achieving what’s required. This is something that I’ve been thinking about a lot lately. Not information sources about antimicrobial use, but about how we can shift the culture toward that of an infinite rather than zero sum game. How do we build in constructs that make people feel valued, and motivate through progress and growth in contribution rather than inspiration and shame? What types of information would help to foster a culture where being the vanguards of QUM isn’t about professional identity and tribalism, but social responsibility?

the risk is we’re going to get more and more resources thrown in to identify what’s wrong with what people are doing rather than what is right. And that’s a big problem.

This! This pretty much sums up where I think we are at the moment with the Pharmacy profession. We’re so focussed on using information about what’s wrong and demonstrating all the problems relating to medication safety, and how much inappropriate prescribing there is in aged care, and everything else that justifies our role, and it becomes all consuming. Lets put energy into implementing innovative solutions, building a better culture, making real change.

 

 

Learn it All

One of my frustrations in life at the moment is committing to listen to a podcast episode only to find out that it’s a bit of a dud. It doesn’t happen all that often, but yesterday it did. There was one redeeming minute though. A minute that contained two phrases that struck me.

The first:

Don’t be a know it all, be a learn it all

Followed up quickly by

What you needed to get you here isn’t what you need to get where you want to go

Like real gold, 1 minute of insight made getting through the other 60 minutes totally worth my while.

 

 

Growth Hurts

I’m sitting here in a comfortable position on the couch avoiding getting up for an inevitable trip to the bathroom. Why? Because of delayed onset muscle soreness, that’s why.

If you read yesterday’s post you will be aware that I have recently reinitiated my running career. Only, my body hasn’t quite caught up with my aspirations yet.

Growth is good for us, but it can hurt. And that’s ok. Discomfort doesn’t have to be avoided, it can lead to something good.

Getting un-stuck

This time last year there was no way that I could run 5km without stopping. Maybe it was just a change in heart, maybe it was because I’m coming up to turning 40, but I made the decision to do the couch to 5k program and pretty soon I was running 5km multiple times a week. I got up to doing a 10km run which I felt pretty good about. But I only did it once. I got complacent, quick.

I could make excuses about hayfever season and stuff like that, but honestly, this is classic behaviour for me. Throw myself into something to learn enough about it so that I can prove I can do it, and then let it wither over time or abandon it altogether. I get into ruts pretty quickly with things. I wouldn’t say I’m getting any better at avoiding them, but I am getting better at noticing that I’m in one and building some sort of structure to get myself out. If I want to of course. For some things, like cold process soap making, doing it a couple of times in my life time is quite ok with me.

But running is different. I really do enjoy it as a form of exercise and processing my thoughts. I never stopped doing it completely, but I have felt myself getting lazier and avoiding it more in recent times. So a re-jig was in order. Enter the Garmin training plan. I’ve got myself a virtual running coach. And it’s kind of fun, it’s changed things up a bit. I can still be lazy, of course, but there’s some level of accountability and challenge to do better. I like that. I know there are other options, like running groups and stuff like that, but running is a solo practice for me. So coaching it is.

As I think about this, I reflect on my post yesterday, about missing the professional development structure of the hospital environment. The healthy competitive environment where accountability and challenge are ever present. It was hard to stay in a rut when I was working in the hospital. There was always someone who was prodding me to do better, or a new challenge or opportunity opening up or job to apply for. But this isn’t how it is in the community-care sector. It’s so self-directed. So isolated. It takes some serious effort and self-reflection to keep growing professionally when no one’s really looking.

Take HMR/RMMR pharmacists for example. Everyone gets paid the same base rate, so long as you continue to get referrals and get through them at a rate that pays you a reliable wage then you’re doing ok. If the purpose of your work is to pay the mortgage then you’ll be fine with that. But if you’re looking for greater fulfilment in your work (e.g. have a more collaborative approach with GPs, take on more challenging cases, get involved in projects or teaching) or want to grow your business then you need to actively change things up. It’s not going to get gifted to you, you have to make it happen. You have to differentiate yourself by acquiring and developing skills and professional attributes. And it might not be that obvious how to do that if it’s sitting in your blindspot.

So what’s out there to help these people? From my personal experience and interactions with colleagues, I don’t think there’s anything that’s meeting these needs for the broader workforce. CPD points to meet registration criteria, sure, there’s tonnes of that. Support for early career development, there are many programs steered toward their needs. But we’re not all early career and we still need help with career development, and that’s totally ok.

I don’t know why it is this way that the focus seems to be so much on early career. Perhaps because it’s easier to get newbies ‘on the right path’ than it is to deal with disgruntled realists who are bordering on cynical. Well, bugger that. I mean, I’m obviously biased but I think us disgruntled realists have a lot to offer. We just haven’t got the right venue. Lets not wait for someone to gift this to us, lets build it ourselves.

Lets build somewhere that provides meaningful engagement with our peers where we can safely share our practice. Somewhere that values our contribution simply because we care about doing good work. Somewhere that offers a range of opportunities to challenge us to meet our goals and achieve greater fulfilment in our work.

 

Things I Miss About Hospitals…

It’s been just over six years since I worked in a hospital, and nine since working in a hospital pharmacy department. There are some things that I’m happy to be rid of (office politics, anyone?) but there are a few things that I really miss about that hospital work environment.

  1. Being part of a multidisciplinary team. One where there is an understanding of each others role in the team, their value and contribution. One where you treat each other as colleagues, regardless of your professional background.
  2. The ability to ask “what do you think about this…” to any number of readily available colleagues who you trust will provide some sound intellectual input. Not only can this validate your thoughts/give you confidence, but it also illuminates your blindspots. Both are good. Both make you a better professional.
  3. Learning from observing other people’s practice. Other pharmacists, doctors, nurses, allied health. You have so much opportunity within the hospital environment to understand other peoples roles and how they approach clinical decision making and patient care. Observe and appreciate differences. It provides such a deep learning experience if you’re open to it.
  4. Ease of communication. It’s pretty easy to get in touch with the people you want to talk with in a hospital. You can often even talk with them face to face. There’s a shared clinical record, network drives, staff directory, pagers…so many functional communication channels to take for granted.
  5. Professional development opportunities. I can’t say that I highly valued the concept of line management and annual reviews when I was working within the hospital system, but now that I’m out of it my opinion has changed. Having some guide rails and accountability can provide you with a lot of opportunity for growth and ultimately enable you to produce better work if you’re open to it, especially early on in your career.

Now I’m not saying that these things are entirely absent in community-based care settings, but they’re a lot harder to come by. Sure, we each have colleagues we can get in touch with to run stuff by, but it requires more effort and your network of peer support is more limited. Professional development rests heavily on the self-direction of the individual. Again, this can be ok when things are going well and you’re being challenged, but more difficult if you feel like you’re in a rut, having difficulties in your personal life or you’re simply not self-reflective. As for communication? Well, it’s just bloody hard work. So inefficient. So much time wasted. I mean faxes…do I need to say anything more than that?

I think there’s a pretty obvious opportunity to improve on where things are currently. And I don’t think I’m being idealistic in saying so.

 

Shipping It

It’s all well and good to know all the theory about the 80/20 effort and all that stuff. It’s another thing to actually put it into practice and accept that oftentimes, shipping something that is good at the right time is much better than shipping something that’s near perfect at the wrong time.

Yesterday I decided to start shipping. I’ve been working on this interdisciplinary online community for strengthening community based care for months now. I’ve talked to people about it and listened to their perspectives. I’ve engaged in other online communities. I’ve learned about business stuff. I’ve written copy for the site, set it up, started using it with a couple of colleagues. I know it’s not perfect, but it’s good enough to start. And I know I’ll never really know what works and what doesn’t unless I put it in front of people. Unless I risk failing and feeling embarrassed and uncomfortable.

So I shipped. I started inviting founding members. I will jump off the cliff and build the aeroplane on the way down.

And with that, Traversity has been born. Will it survive and grow to maturity? We shall have to wait and see how good I am at building aeroplanes!

What Ifs

Sometimes I come across children’s stories that make me think they were written for the parents. Arthur and the What Ifs is one of those stories.

A little guy named Arthur is filled with music but psychs himself out by thinking about the what ifs. What if he’s not good enough. What if people laugh at him. You get the idea. But the music is still inside him, it doesn’t go away.

One day Arthur gets a flyer for an open jam session and he again starts to think about the what ifs. But this time, for the first time ever they are good what ifs. What if it’s fun? What if he’s actually good?

This shift in mindset doesn’t solve all of his issues (this is a children’s story, not a fairytale) but it gives him enough confidence to fashion himself a disguise and join the jam session. He joins in and gets so consumed by the music that he doesn’t realise he is no longer in disguise and playing music out in the open where everyone can see him. And enjoying it. This leads to his new life of playing in the band, Arthur and the What Ifs.

How we talk to ourselves is so powerful and so hard to get past. Reframing sounds like such a load of jargonny bullshit. But what if it leads to something great? Isn’t it worth the experiment? I tend to think yes, it is.

Being Judgemental

I have a strong tendency to be a bit too judgemental and intolerant of others. Ive written about it before. Its something I’m consciously trying to improve. But I feel like there are some circumstances where it is still acceptable.

Take small children riding a scooter at speed on a footpath for instance. Make your kid wear a helmet for God’s sake! Didn’t you learn about the impact of heads hitting concrete curbs when Patrick died on Offspring?

And for a work related one, how about oxybutynin and donepezil all packed together nicely in a dose administration aid? Not good enough I think. We need to do better.

Knowing When to Quit

How do you know when it’s the right time to quit something instead of just relentlessly pushing through? I’m not sure. But it’s something I’ve had to face up to this week.

I’ve written before about my frustration with receiving anonymous feedback. I’ve had some pretty bad experiences. Well actually, when I think about it, the bad experiences have all been anonymous reviews conducted by pharmacists. I think it’s because most pharmacists like to distil the world down to black and white. They like to be right. And that’s just not the way I see things, so it creates some pretty strong dissonance.

A while ago I decided that if I was going to be studying and writing about the HMR process then I should really get accredited by the AACP. I figured it would help me in understanding the position of the accredited pharmacists. Improve my capacity to empathise. Get to know the community of practitioners.

It’s not so much that I want to actually pursue a career of providing HMRs. In fact, I used to be accredited with the SHPA and never did a single one so I let it lapse. Back then, I was doing medication reviews for the community palliative care team. I thought if I was going to do them I should at least make sure I met the standard, so I sat the CGP exam, filled out my paperwork and paid my fee. Easy.

If only I could say the same ease existed with the AACP process. I can’t. I definitely can’t. In fact, I’ve found it so anxiety-provoking that I have just sent an email saying that I’m not going to pursue accreditation. Yes, I am quitting.

It’s not because I got negative feedback. I got negative feedback the first submission, I had my little rant, then I sat down and revised it and did it properly. Dare I say that I actually quite enjoyed it and learned a few things. I was almost looking forward to the next case. But then I got the feedback telling me I was still not yet competent. That they could see I’d improved so I was lucky enough to get to submit to the same reviewer for a third time. And I could pay another $70 for that privilege.

I let it sit for a while. I told myself that it’s just one of those things to endure. That I just have to play the game. Don’t take it personally. I thought I would approach it like any other peer review and go through the comments one by one. In peer review you’re not expected to blindly accept all the comments, so surely this was the same.

As I sat down and went through each of the 33 comments, a new reality revealed itself to me. The reality where you either produce work that you think is valid, or you produce work that appeases the reviewer – they are mutually exclusive outcomes. And this reality stressed me out.

I’m not really what I would describe as an anxious person. I can take on multiple responsibilities and manage them pretty well without them keeping me up at night. But this was keeping me awake. Multiple nights, there in my head. And it was making me anxious, and angry, and generally not feeling very good.

So, rightly or wrongly, I decided that paying more money and spending more time on this process for learning sake simply wasn’t worth it. I decided that I shouldn’t let sunk costs influence my future decision making. I decided that there was no way in hell I was amending my report to address some of these ridiculous recommendations. Three of the 33 were kind of reasonable, but the other 30 could not be entertained. I ran it by some colleagues first. I’m not stupid, I needed to know I wasn’t being sensitive. They validated my frustrations.

So I quit. I’m a quitter. And I don’t feel anxious anymore.

Going Analogue

There’s just something about tactile, old school methods that just feels better. Like scribbling notes in a notebook. Or moving post it notes across a board from the ‘to be done’ section over to the ‘in progress’ bit. It brings an element of satisfaction. Its made me feel like I’ve accomplished something today, even if it was just a bit.