Human factor, leadership and communication are main cause of harm to the patients-Paul Barach


 State of the Art Session-III at SMDC Third Int. Conference
Human factor, leadership and communication are
main cause of harm to the patients-Paul Barach
Neonatal Intensive Care Units have saved millions 
of babies around the world-John Lanton
Population explosion in Pakistan does not
help improve health indicators-Z.A.Bhutta

LAHORE: The face of medicine is changing all over the world. Teams are needed to have good surgical results. Human factor, leadership and communication are the main cause of harm to the patients. This was stated by Prof. Paul Barach the guest speaker from United States while making a state of the art presentation in the last plenary session during the Third International Conference of Shalamar Medical & Dental College on February 3, 2019. He was speaking on “Assessing and Improving technical and non-technical skills in Interprofessional learners”. This session was chaired by Prof. Javed Akram Vice Chancellor University of Health Sciences Lahore.

He started his presentation by highlighting the patient safety studies twenty years on and pointed out that one in ten patients had in-patient care in hospital. Studies have shown that there is 36% more mortality if the patients are operated upon on weekends as compared to the week days. However, there is no difference in mortality in emergency cases. Comparing medicine with aviation industry Prof. Paul Barach stated that no one will ever fly on week end if there was any risk of dying on such flights. Increased cardiac mortality in paediatric patients in UK which was investigated helped to improve the situation there. It is extremely important that we should train the teams. It is also important to know how to train these medical teams for which political pressure is needed to ensure compliance. One of the great surgeons had remarked that “if nurse follows my order, eventually everything will be alright”. It is also said that if surgeons are blood, the anesthetist is the brain. During the last year over five billion passengers flew on different airlines and there has been no air crash. That shows how the aviation industry maintains its standards.

 Prof. Zahid Bashir presenting memento to Dr. Faisal Sultan who was the chief guest in the
inaugural session while on right Mr. Shahid Hussain is presenting a memento to Dr. Jeffrey 
Yen Lin during the first plenary session at SMDC conference.

Continuing Prof. Paul Barach said that we must know how do teams learn and do well? There is a major gap between what is said and what is registered. Appreciation for a system is essential. There are factors which affect during nurse and physician communication. Meaningful feedback is very important. Standard communication improves output. There are techniques to minimize distractions. It is essential to ensure that there is limited number of people in the operation room. He also laid emphasis on de-briefing of the staff, trust, and communication and shared model. Performance based feedback is important. Every team member must get feedback on their performance. Training should be customized to local circumstances. Studies have showed 18% reduction in mortality with team training programmes. We need to produce patient safety scientists. Truth telling is extremely important and trust is most important element to breed. He then talked about the peer to peer learning and assessment. Personal improvement assessment was more important than by coach. He concluded his presentation by highlighting the importance of communication, team consolidation, and factors affecting the healthcare industry and how this integration can take place.

Dr. John Lanton was the next speaker in this session whose presentation was on “Decisions for babies born at borderline of viability”. He pointed out that Neonatal Intensive Care Units (NICUs) have saved millions of babies around the world. However survivors face a lifelong problem. There are some ethical issues involved. Should we let babies die because they have many problems and taking care of these babies is very high? When we talk about ethics in such cases, all choices are bad. There are legal issues involved. If a baby suffering from bacterial meningitis survives, the baby may have severe neurological problems. There are practice variations in United States. When asked is impairment is worse than death, 55% doctors and nurses replied “Yes”. However all the parents do not feel the same way? One does not know how long these babies are going to survive? These have to be personalized decisions making. Rational of autonomy allows the parents to make the final decision bases on personal values. Doctors should help parents understand their own values. There are numerous cost effective studies on NICU patients. If the babies stay longer in the NICU, there are more chances of their survival. However, if they stay longer in a medical ICU, they are more likely to die. We need to ensure justice in resource allocations, distribute if fairly. We must take into account the available resources. Survival rate is different at birth weight and gestational age. Research is needed to understand these issues. He concluded his presentation by stating that now survival rate of premature babies has improved all over the world. Many parents favour treatment and treatment is also now cost effective.

Mr. Shahid Hussain Chairman BHT and Prof. Zahid Bashir Principal SMDC presenting mementoes to
Prof. Javed Akram (Chief Guest), Prof. Paul Barach, Prof. John Lanton and Prof. Z.A.Bhutta
during the third State of the Art lecture session at Third International Medical
organized by Shalamar Medical & Dental College from 1-3, Feb 2019.

This was followed by Prof. Zulfikar A. Bhutta who in his presentation discussed “Opportunities for addressing maternal and child health in Paksitan: How can we break the log jam”? The challenge that we face for newborns is inequalities in health care. About ten million children die under five years of age. The new goals set by the WHO are to ensure maternal health to 76% and 66% reduction in child mortality. However, he remarked that averages have lot of differences. China, Brazil, countries in Middle East have achieved reduction in child mortality. Reduction was very low in South Asian countries. Pakistan is in South Asia and Pakistan has recorded the slowest reduction in mortality. For reduction in less than five mortality, neonatal mortality is a test. It has now started to reduce.

Continuing Prof. Bhutta remarked that we have made lot of progress, our per capita income has increased, GDP has gone up, and we have made economic progress. However, we have not made much progress in newborn survival. Our population growth has not slowed down. We still have a 3.6% fertility rate; literacy rate has not increased much. Population explosion does not help improve our health indicators. He opined that female education should be given more importance. Health indicators are very bad in Sindh and Baluchistan provinces in particular. Skilled birth attendants can play an important role. We have a very high ratio of physicians per thousand populations in Asia but the ratio of nurses and midwives is very low. There are many social and cultural factors. People from affluent class do not consider nursing a good choice for their daughters and sisters and only those girls opt for nursing that have no other choice. In Pakistan almost 85% of physicians are settled in urban areas. The people have no faith in quality of care at mid level. There are no qualified people at the secondary level at most of the healthcare facilities. Critical illness is missing at secondary level. According to studies 3.50,000 children die on the day of birth and over eleven thousand maternal deaths are taking place in Pakistan every year. About 106,500 female suffer form intra partum death; these deaths take place when mothers are in labour. Maternal nutrition is also important. The Cesarean section rates for Punjab are 23.6%, for Sindh 17.8%, for PK 4.8% and for Baluchistan 1.3%. Skilled birth attendants are available to less than 20-30% pregnant women in Rahim Yar Khan District in South Punjab. There are problems of vaccination, treatment provision and oral rehydration therapy. There is no change in rural areas as regards early marriages. Policy makers must analyze this data critically.

 Some of the invited guest speakers Prof. Paul Barach, Prof. John Lanton, Dr. Zakiuddin
Ahmad photographed alongwith Mr. Shahid Hussain Chairman BHT, Prof. Javed Akram
VC UHS, Prof. Zahid Bashir, Prof. Bilal Bin Younis and others during the concluding
session of Third International Medical Conference organized by Shalamar
Medical & Dental College from 1-3, February 2019.

Speaking about the solutions Prof. Bhutta referred to provision of community outreach services for specific high burden illnesses. Community health workers should be a member of the healthcare team. We must ensure some sort of referral system from Basic Health Units to Rural Health Centers and Tehsil Headquarters Hospitals. Link it with quality of care in the nearest District Headquarter Hospitals. People should also be encouraged to use these facilities. We all must get engaged and become a part of the solution.

Prof. Bilal Bin Younis who was co-chairing this session in his remarks said that we need to communicate with each other, organize training programmes for team work, and develop health infrastructure and human resource. Lower cadre health workers should be fully involved and encourage lady doctors to work part-time and they should be provided flexible working hours. We need to customize our priorities keeping in view our needs.

Prof. Javed Akram in his concluding remarks said that better communication; team spirit will go a long way in reducing morbidity and mortality. We need curriculum changes for undergraduate medical education. We at the UHS have now encouraged debates and sports to encourage that all healthcare workers work as a team. Doctors, nurses, allied health workers are all important members of healthcare team. We are weak on hospital management side. Most of the doctors have no training in hospital administration. That is why UHS has stated a Masters programme in Hospital Administration. We are a Muslim country hence religion must come in when we take some decisions. We have no right to life but we doctors can work as an agent to save life. Informed consent of the patients regarding their treatment is important. Parents wish their child to live irrespective of the fact how severely ill or impaired they are because they do not wish to live with a guilt throughout their life. That is why they do not wish to kill their impaired babies. We have lot of disparity in medical, nursing and allied health sciences. So far there is no regulatory body for allied health sciences. We in the UHS are trying to regulate more than forty medical schools and as per different surveys only 23% of female doctors practice medicine after getting married. Thus we waste lot of talent. We need to look into these issues and find a solution, he remarked.