In Episode 32 of Pomegranate Health, we discussed cognitive error in diagnostic reasoning. On this episode, we take a look at systems pressures that increase the likelihood of medical error, crystallised by the recent prosecution of U.K. National Health Service (NHS) paediatrician Dr Hadiza Bawa-Garba. Almost half of diagnostic errors are due to a combination of systems errors and individual cognitive error. Obvious systems effects come into play in understaffed acute care units; if a clinician is forced to see too many patients without enough time to make careful examinations or reasoned decisions, errors become more likely. The stepping stones of ordering, receiving and reviewing diagnostic tests and scans also allow much opportunity for error and delay. Guests on this episode discuss mechanisms to improve efficiency.

Cannabis is a plant rich with potential therapeutic compounds and centuries of cultural resonance. However, only a few of the claimed medical effects of the plant have been proven by rigorous clinical trials in people. These include spasticity and pain in multiple sclerosis, chemotherapy-induced nausea and vomiting and some cases of epilepsy. But for many other conditions, systematic reviews have concluded that meaningful clinical recommendations cannot be made. In this episode, we explain how important it is to separate the effect of various cannabinoids in a systematic way, and why well-regulated research and prescribing will be safer for patients.

This is the first of two episodes about errors in diagnostic reasoning. Misdiagnosis or delayed diagnosis occurs in 10-15 per cent of acute presentations, although fortunately only a tenth of these lead to serious consequences. But of concern is the fact that this figure hasn’t changed in three decades, despite progress in clinical knowledge. Cognitive errors result from jumping to conclusions on the basis of intuition and incomplete information. There are a hundred different types of such bias. On this episode, the most common types will be discussed, as well as strategies to force a more considered process of diagnostic reasoning.

‘Ngā Kaitiaki Hauora’ translates as ‘guardians of health’. This podcast emerged from a meeting near Auckland organised by the RACP’s Māori Health Committee in November 2017. Members of various medical colleges and institutions came together to share perspectives on the delivery of health care to New Zealand’s population of Māori and Pacific Islander people. This conversation comes in the context of the Wai 262 claim, which is forcing a re-examination of the Crown’s obligations to the Māori population under the Waitangi Treaty of 1840.

Figures about burnout, depression and suicide are often reported on in the health workforce. These rates are typically twofold higher than they are in the general population, according to studies from New Zealand, Australia and around the world. Causes often given for psychiatric distress in the medical profession are the gruelling hours, the pressure of perfection, the unforgiving culture and the stigma associated with mental health issues. This episode examines how the system affects the individuals within it, and what can be changed for the better.

Drug-drug interactions might be responsible for a million hospitalisations in Australia every year. They have become more frequent over the decades, as more medications reach the market. More than half of people over the age of 75 are on five or more prescriptions—a state referred to as polypharmacy. This episode examines some of the systems that have led to current rates of polypharmacy, and some strategies for deprescribing. We also discuss a review from the Internal Medicine Journal on the common drug interactions physicians should be most concerned about.

Transitioning from trainee to consultant marks an exciting and daunting and step in a clinician’s career. Suddenly you take on responsibility for everyone on the ward—both patients and other staff. While the clinical skills have been hammered in over years of training, the ‘hidden curriculum’ can be harder to pick up. This episode captures the experience of striking out as a leader, manager and mentor to others. At the same time, recognising limitations and knowing when and how to seek help is all important.

For years the management model for asthma has been empirical. The more serious the disease, the more the dose of controller therapy is increased. But this doesn’t work for everyone and a more rational approach involves identifying one of three distinct pathological pathways. This episode describes emerging diagnostic tools therapies such as monoclonal antibodies that are targeted to specific disease phenotypes.

Uncertainty is a frightening but unavoidable fact in every speciality. In the second of a two-part series, we look at the stigma and disorientation experienced by patients with medically unexplained syndromes, and some behavioural interventions for functional disorders. Since treatment outcomes are never guaranteed, we also discuss how a patient’s expectations must be managed from the beginning of a consultation, and the importance of long-term coping strategies.

Uncertainty is a frightening but unavoidable fact in every speciality. In the first of a two-part series, we examine the culture within the profession and general public that expects nothing less that perfection in medicine. We also ask whether hospital training might shelter younger doctors from the experience of complex, chronic conditions, and how much the simplicity of protocol can be relied upon.