Transcript

MIC CAVAZZINI: Welcome to Pomegranate Health. I’m Mic Cavazzini for Royal Australasian College of Physicians.

CAROLYN:           This is 8 month old Jack he came to the ward overnight with a simple febrile convulsion. Had been unwell for 24 hours with vomiting fever and diarrhea…..

MIC CAVAZZINI: It’s the paediatric ward at an unnamed hospital and a rapid response has been called for an 8 month old boy who is seizing after an admission for febrile convulsion. Leading the rapid response team is Elodie and she doesn’t hesitate to ask registrar Eliza to cannulate the patient with the intention of administering midazolam.

ELODIE: It might take a bit before Eliza has got a cannula in.
ELIZA:    Can I just quickly check which bloods we’d like sent?
JANE:    Carolyn can you help with Emma?

MIC CAVAZZINI: Emma is trained as an ED nurse and starts measuring up the midazolam. But there’s just one hitch.

ELODIE: Can we go for IV. 0.15mg per kilo please.
RENEE:  You have not been successful with your cannula.

MIC CAVAZZINI:               This is, of course, just a simulation. The patient is a rubber mannikin, but a sophisticated one that coughs and grunts and can be wired up for monitoring of all the vital signs.

ELODIE: Airway, back to that?
NOUR:  Grunting, but sats are 92%

MIC CAVAZZINI:               This mock ward is at the Kids Simulation Centre at the Sydney Children’s Hospital. It’s run by a dedicated Critical Care Simulation Team, which includes Clinical Nurse Specialist Renee Byrne. In the scenario you’re listening to, she plays the role of dungeon master, reporting back to the participants details that can’t be mimicked by the mannequin.

EMMA: Rene what was his blood sugar?
RENEE:  Blood sugar 6.2.
EMMA: Did we check the temperature, Renee in the meantime?
RENEE:  No one has checked the temperature. It’s 39.5
EMMA: So, are we controlling the seizure and then potentially covering for sepsis as well? Or what’s your plan? What are you thinking?
ELODIE: Let’s start with cephtraxone. We’ll go for 100mg per kilo dose as per meningitis guidelines and follow the midaz with that.

MIC CAVAZZINI:               The participants in this simulation aren’t critical care specialists, they’re mostly advanced trainees in paediatrics. The workshop has been developed to help them brush off cobwebs and regain confidence after being on extended leave, usually to have kids. The course is actually called Paediatric Returnees After Maternity or PRAM. Get it?

Elodie checks for signs of meningitis or sepsis while Eliza has another go at IV cannulation. She’s told that this too has failed, and that the patient’s jaw contractions barely allow them to get an oral wafer in.

RENEE:  Some of that’s gone in.
ELIZA:    So, we’ll go IO. What do you think?
EMMA: Do you want to go IM before we do IO so we can control the seizures.
JANE: Do you want an IO? Has anyone put in an IO?
ELODIE: We were just talking about that.

MIC CAVAZZINI:               Nurse Jane, who is a known confederate with experience from ED, suggests that IM will take too long to act and volunteers her experience at handling the intraosseous driver. This is actually a procedure that can be performed on the simulation mannequins.

Elodie asks for the blood and marrow returned from this to be sent to the lab. Midazolam is finally administered and the simulated toddler stops seizing. With the situation stablised, Eliza gets on the phone to the paediatric consultant, another confederate. They recommend calling ICU. And so, ends the scenario.

The participants then sit down for a debriefing session, to share their experience of this simulated crisis. As they’ve all been off work for several months, the feeling of rustiness or sluggishness is a common one. Here’s Elodie again, who gave birth almost four months ago and will soon be starting a senior registrar role in community paediatrics.

RENEE:  How did that feel to be in that scenario?
ELODIE: It felt very chaotic.
RENEE:  Can you tell me a bit more about the feelings.

ELODIE: It was such a great group of people who all had really good suggestions, and they were all saying them up to me at once. It was actually really hard to manage. Like, you're going, “Do you want to do this?” And I’m like, “Yeah”. And Emma would say, “Do you want to do this?” Yeah. And it was like, oh crap, now I need to, like, allocate people to do those things and figure out what order all those things should happen. So, it was actually really good from a cognitive load. I was really just managing all the people's brilliant brains, but that was actually quite tricky. Because quite a few times, I had almost simultaneous suggestions, to the point where sometimes I'd be like, “Yes, we have done that brilliant suggestion because two seconds ago, somebody else suggested that”. So that was quite tricky, and a good reminder of why some people ask for quiet in a resus. so that everyone who has all these brilliant suggestions can also hear when somebody else has already said it. Sorry, that was a really chaotic explanation for why it was chaotic.

MIC CAVAZZINI:               Here’s Emma the ED nurse again.

EMMA:        I felt like my brain was still trying to catch up. So, I'm like, someone seizing in front of me, and you know the pathway, right? But then I was like, is it a sugar issue, is it a sepsis issue, I wasn't sure what pathway, so I was a bit lost of which one I'm going down. So, that's why it was probably like verbal diarrhea just coming out. And then I was kind of like, “Oh, how do I draw up this medication?” Just that slowness, you know, like, “Oh my God, zero point zero what?”

MIC CAVAZZINI:               After the debrief, three more participants take their turn in the sim room. This time the patient is a 6 year old girl on the ward experiencing a severe asthma exacerbation. The immediate management involves a non-rebreather with continuous Ventolin and Atrovent along with IV magnesium sulfate and hydrocort. Ultimately, the care is escalated to ICU. You’ll hear reactions first from April who’d been responsible for circulation, and then Stephanie, who was on airways. Both are returning after their second child and nearing the end of their paediatric training.

APRIL: I felt like I had three stages, personally. Deer in headlights, then I flapped, then I got into it. That’s honestly what I felt like a little bit. Yeah, deer in headlights when it started and everyone's doing everything, everyone's talking over each other. And I was like, Oh God, where am I? And then someone passed me your computer, and then I'm scrolling, and not really looking at what I'm doing, but looking at the patient. And then Claire, I think, started to talk and lead. And then I was like, “Okay, I know what I'm doing.”

STEPHANIE: I knew the situation, knew it was asthma and was just like, what do I do? Trying to dig through the files in my brain, thinking I know this, where is it? And then was like, of course, it was in front of me, that’s what we do.

MIC CAVAZZINI:               The simulated scenarios you’ve heard are the culmination of a full day’s worth of practical sessions and cognitive refreshers. There is a growing pool of literature about the real or perceived deskilling that occurs when one takes extended periods away from practice. An important guide to the thinking around this is the UK General Medical Council’s review from 2014 titled “Skills Fade”.

Many doctors confess to having anxiety about returning to work even before they’ve attempted it. One general observation from this report is that “self-assessment of competence doesn’t necessarily match the findings of objective assessments.”

The evidence for deskilling in medicine isn’t as well-quantified as it is in other fields like aviation, where flight simulators can replicate complex and realistic scenarios for large numbers of pilots. But there is empirical research assessing competence in procedures like catheter insertion or knee aspiration at various time points after training.

This suggests that that six months without reinforcement is enough for most people to lose their touch. The drop-off is steeper at the beginning and then there’s a more gradual decline as months become years. Generally speaking, skills decline faster than knowledge, and predictably, more consolidated learning is better retained. Here’s workshop coordinator Sasha Symonds, dual specialist in paediatric emergency medicine and intensive care, and you’ll also hear Emma’s daughter toddling around and drawing a few smiles.

SASHA SYMONDS:           The first time I came back, I couldn't remember the word extubation, which I would use, like a hundred times a day. And I was like, “You know when you take out the tube,” and my boss looked at me like, “do you not know the word extubation?” It was so embarrassing, but it’s stuff that you use every day.

MIC CAVAZZINI:               From a neuroscience point of view, the knowledge is encoded there but you just need to lower the threshold to access it.

SASHA SYMONDS:           And I think what I realized coming back, and when I've spoken to other people, the knowledge is absolutely there, and once you've seen it, or even done it, once it's then at your forefront, and you never have to refresh it again. So, that's the purpose of this. Super, relatively common stuff that we would see every day, all you need is for someone to say it once to you, then it becomes bread and butter again, but it's the first encounter that becomes confronting.

MIC CAVAZZINI:               At today’s workshop, the participants go over some cognitive tasks like calculation of fluids or drug doses and interpretation of chest x-rays. Then they practice some hard skills like advanced airway management. But it’s not just about rehearsing the muscle memory required for intubation, say. There’s also a refresher on technical knowledge, as some devices or guidelines have been updated since the clinicians were last on the job. In one classroom there are mannequins specifically for neonatal lumbar puncture that even spurts saline fluid when the tap is successful.

LUCY: Like the distance between the skin and the spinal cord helps me conceptualise exactly how far to go in.

MIC CAVAZZINI:               Here are Lucy and Paula. Both are advanced trainees who have had a year off clinical work and are starting back in community paeds. In Paula’s case the break was for a full-time teaching role rather than maternity.

MIC CAVAZZINI: Is it a real sense of tactile feedback that you get?

LUCY: To be honest, they talk about a pop, which you might get in like adults or older kids. But in babies, sometimes you might feel a little give. But often I just go slow slow slow until it starts to drip.

MIC CAVAZZINI:               And out of the three stations this morning is, how does this compare on the difficulty rating?

PAULA: It’s just almost like riding a bike in the sense that it's like something I've done a lot of, but not for a very long time. So, it's just getting that feel back, I guess.

LUCY: And you're also usually doing this skill under a bit more calm. Whilst intubation or bag-valve-mask is often a bit more of a big sort of, a lot of people in the room, lots of senior support, if needed. While this you might just be doing on a ward in the middle of the night, you know, in a rural town, so. Which in some ways makes it easier, because it's a bit more calm, you’re in your own space.  I couldn't help but feel my baby's back and go, oh yeah that’s the spot I’d go. Isn’t that gross?

MIC CAVAZZINI:               How old is your kid?

LUCY:    He's eight months. Almost eight months this week.

MIC CAVAZZINI:               Does it play on your mind at all when you think of going back on the job and handling a child the same size?

LUCY:    I already find just seeing movies, I'm more emotional when things happen to kids. So, I think I'll come back with a different level of empathy and understanding. Like, before I would just say, “Come back in for a clinic,” to a parent. And now I think coming back to a clinic means like, sorting out everything, having everything packed, having a kid in between a nap or a feed. If they get to an appointment, like, oh my gosh, you're amazing. Before I was, less aware.

MIC CAVAZZINI:               People take time out from their medical practice for many different reasons, but career breaks to raise children are more common than ever before. In the 1960s women represented barely a quarter of students in medical school whereas now they make up more than half. Not all of them will choose to have children, but for those that do, the most fertile years overlap with the most intense periods of medical training.

In a study of the UK’s National Health Service pay records it was shown that over a six year analysis window, 18 percent of female doctors and dentists under the age of 50 had taken at least one spell of maternity leave. At any point in time, almost 4 percent of women working in the hospital and community setting were on mat leave.

So, there is always going a steady stream of women rejoining the workforce after a significant interruption to their work and training. The rate will be even higher in specialties like paediatrics and obstetrics and gynaecology, where 70 to 80 percent of the workforce is female. Without supports like the PRAM workshops, many returning doctors will be lacking in self-confidence and quite possibly not performing at their best.

There’s a 2020 study investigating the relevant risk factors which has the title “Predicting risk of underconfidence following maternity leave”. Interviews were conducted with 146 paediatric trainees from 12 Deaneries around the UK, asking how long it had taken for their confidence to return to pre-maternity levels. About a third reported that a month was enough to regain confidence, and for another third it took up to three months. But for the remaining third it took longer than that.

Those who had taken more than one month to regain confidence were examined more closely to find what might explain that lag. As you’d expect, a longer period of maternity leave was one risk factor for a slower return of confidence, and those coming back full-time tended shrug the nerves off more quickly.

A more interesting finding was the particular difficulty of those returning as stage 2 trainees, rather than stage 1 or 3. So that’s a junior registrar newly entrusted to act without direct supervision. The authors didn’t ask why these stood out in particular, but I suppose it speaks to the increasing sense of imposter syndrome as one progresses to greater levels of responsibility. Dr Sasha Symonds described a related incident that occurred during her training years.

SASHA SYMONDS:           Yeah, so I think the thing is, when you come back after a period off, you could have all the knowledge in the world, but the confidence is not there. So even though you decide on a situation or a management plan, there's always going to be a doubt, because you're always like, is that actually what I remember? Have I forgotten? Have things changed? And so, you question yourself a lot, even though your knowledge might be fantastic. And particularly when you're communicating with somebody who's been in the workplace for a lot longer, it becomes even harder, and the more senior they are, it becomes harder.

Like I went to do back to do my adult training—so a year away from Sydney Kids—and I'd come back after my third kid. At Sydney Kids, I was fairly senior, everyone knew me. So I'd taken eight months off, and then come back to adult land, and I felt not very confident, and there was a baby that came in quite floppy and we had to resus them.

And then one of the girls, one of the nurses who knew me, called me over because she knows that that's my area of expertise. And I came in, and on my sticker, it said, like SRMO, which is like a junior doctor, because in adult land, that's what I'd come back as. And so, then I was giving out instructions and like the seniors were like, “We don't need to hear from junior staff. Can you be quiet?” And they were really not handling the situation well. And then I was like, “Could I just say…” and they were like, “We don't need to hear from you”. And it went back and forth, back and forth.

And then eventually, the staff specialists got up and said, “You don't know, Sasha, but she's actually a senior doctor, she's just come back from mat leave.” But at the time, I didn't feel that confident, because I just come back from mat leave, and I was in a different hospital and different environment. And so it does matter that you know the people, and you know the people that you're working with, and they know you. But it's hard when you step out of that situation, I think. Anyway the baby was fine.

MIC CAVAZZINI: Of course.

SASHA SYMONDS:           We instigated as part of our communication pathway, the rules of two. So, if two people are questioning what you're doing, you need to stop and get a general consensus. So, if I was, I was choosing an intubation drug, and somebody said to me, “Do you really want to use that drug?” And I ignore them, and then somebody else says, “Do you want to use the drug?” Somebody can say to me, “That's two people have questioned it”, and then you have to sit down as a team and say, “What do we think? This is what I used a year ago. What do you think about this?” And it just allows a conversation about why I'm choosing it or why I'm not choosing it.

What I'd say as a general rule is that nobody ever got hurt by communicating. So even if you're not sure, and you go, “Somebody once told me I should use ketamine, because this patient's, hypovolemic”, and you've got a really senior anesthetist there, I will still often say to them, “Look, I could be wrong, but can I just flag with you? I'm worried about this, or this was what my teaching. What do you think about that?” And it might make them go, “Oh yeah, I hadn't thought about that.” And that's happened to me before as well, but it is tricky. Yeah, I don’t know that there's a right answer.

MIC CAVAZZINI:               Some time after attending the PRAM workshop I caught up with another one of the organisers to get more insight into what they were trying to achieve. Dr Josephine Goodyer is a Staff Specialist in Paediatric Emergency Medicine and Simulation at Royal Children’s Hospital, Sydney.

MIC CAVAZZINI:               In the podcast, we discuss the predictors of a good return to work, versus less comfortable return to work, and one of them is, unsurprisingly, just having contact with your team, with your workplace, while you're on mat leave, coming in for conversations with your supervisor. “Keeping in Touch”, as the Australian government calls it, these “Keeping in Touch” days. What are the better ways to keep the skills and knowledge fresh? Is it just to attend a grand round now and then? Or is there any formalization to that process that you've adopted.

JOSEPHINE GOODYER:   Yeah, Grand Rounds does that to an extent, but it's quite topical updates. I think that there's a lot of value to the College Lecture Series, both for adult trainees and the paediatrics in child health division now, which is getting more and more topics up. And the reason I say that is because they're bigger topics, they're relatively short, and it's quite up to date clinical practice.

MIC CAVAZZINI:               Good plug there for our eLearning resources.

JOSEPHINE GOODYER:   Both procedurally to an extent and also in terms of guideline-based practice. And it's quite accessible, you can do it remotely. And then there's other forms of CPD that we all have to meet. So, every five years, the suggestion is that we do advanced paediatric life support. Great program across three days. The disadvantage of it often is that it's quite expensive and a challenge to get to, particularly if you've got a really busy life at home and need to work three days of being somewhere else in amongst other commitments and things. And then for skills-based practice, refreshers, there are a fair amount of one day workshops around or half day workshops around that are skills-based, reminders or refreshers around skill acquisition and how you do it. lot of part task trainers, these kinds of things.

MIC CAVAZZINI:               Some of the those same things we saw at the workshop. Cannulation and…

JOSEPHINE GOODYER:   Exactly yeah, just really short, yeah, hopefully a little bit more manageable sessions for people. We talk about, we—the Royal “we” , the paediatric “we”—we don't usually have the same rate of resuscitation, or like big trauma right needing huge emergency surgical intervention that our colleagues in adult emergency practice do. And so, for our trainees, physicians, nurses, whatever discipline, getting access to that and being involved in leadership roles in that, rather than circulation role or airway role, but even airway role to an extent, because usually that goes to our anaesthetic colleagues, given they just have greater exposure, it's just different volume. And that we have less opportunity. And I think simulation is a great way to provide that opportunity to an extent.

MIC CAVAZZINI:               Yeah, and I guess one thing I observed at the workshop was the many different layers of re-immersion that were going on and also those role dynamics, which I think came across really well. Who's the leader and how do we present ideas to each other and digest them. All of that can be simulated just working through a scenario in a tearoom. It didn't necessarily require all the realism of the sim centre.

JOSEPHINE GOODYER:   Yeah and it didn't necessarily require all of the technology, either.

MIC CAVAZZINI:               Yeah sophisticated mannequins, all the things that bleep and give you can give you real-time feedback, but you could imagine in regional hospitals where trainees go, you could conduct a simulation that's more of a role-playing game on paper. I mean, yeah, have you got any advice for people wanting to emulate the PRAM program in less resourced settings?

JOSEPHINE GOODYER:   I completely agree with you. I think simulation is something that can be really mobile, and there's lots of different modalities, and certainly different organizations have a lot of resources available in terms of things like “visually enhanced mental simulations” or VEMS. And that's mainly based out of the Queensland group. And that's something that's really similar to what you've just described, so you can print out and laminate, effectively, a mannequin sized a full sheet, and print and laminate, for example, IV access and a cannula and a syringe. And so, when you're talking through and modelling with low fidelity but high authenticity, what you want to do for this seizing child, you can physically, for example, pick up the cannula, come place it on the printed version of the child. Just so that it's a way and a prompt in terms of that cognitive load and cognitive thinking, and how do we share that in leadership roles within clinical scenarios with the entire group. And I'm glad you mentioned and spoke about the resourcing that we had, because, I'm pretty sure on the PRAM workshop day, the first clinical scenario that I was directing none of the technology worked

MIC CAVAZZINI:               It could be a lifeless mannequin from Best and Less,

JOSEPHINE GOODYER:   So, it could be a mannequin from Best and Less. In Kiribati, I used dolls. And I think it's about trying to view or value simulation as an equalizer. We know simulation works. Does simulation achieve an improvement in clinical skills? Does it improve recognition of a deteriorating patient? Does it improve crisis resource management practice? Does it improve teamwork skills? We know this. We have the knowledge base around it, and the literature tells us that it does work.

It's so valuable starting some of those conversations around we know and appreciate that you have the clinical skills, we know and appreciate that you have some form of guideline based practice we know, and appreciate that you can look it up to an extent, ask a friend, phone a friend, all of these things, we know you can do that. This is what we observed, and this was the outcome of this scenario for this simulation. Why did that happen?

MIC CAVAZZINI: It's just one little point of feedback out of many that you could prompt. But every little bit of feedback is helpful.

JOSEPHINE GOODYER:   Yeah, because sometimes we come up against a really significant challenge to professional identity. So, maybe we have said, for example, “You didn't turn on the oxygen and the patient desaturated.” What we're going to get back probably is, “Well, yes, I did, and the patient desaturated because they were seizing,” for example, because often clinicians find it such a challenge to their professional identity, and it results in this really big form of cognitive dissonance that we all then try and do these mental gymnastics around in terms of trying to justify it for ourselves.

MIC CAVAZZINI:               Along with this idea of skills fading during long stints away from practice, there is another theme that emerges from qualitative interviews with paediatric returnees. And that is the increased distress a medic might feel when caring for very sick or injured children if they have an infant child of their own. At the PRAM workshop, Dr Goodyer and colleagues discussed this with participants during an intimate mentoring session that I excused myself from to give them more space. Dr Goodyer did share with me this heartbreaking example of how emotional resilience can be impacted when the work hits close to home.

JOSEPHINE GOODYER:   So, I have certainly had peers, friends, colleagues, across the years, talk about cases and scenarios that have really prompted them to think about their own children and really challenged them personally and professionally. One case that I recall is a senior clinician when I was a trainee, who I just really looked up to, as in, very experienced, always seemingly had it together, extraordinarily approachable, very knowledgeable, who was involved in the resuscitation of a child that we had some information about in advance, so we were present at the bedside waiting for the arrival of this child who came in critically unwell.

And she was standing there as part of this and had relatively recently returned from maternity leave. And handover started, and the child was transferred from the ambulance or paramedic stretcher onto the emergency department stretcher. And she was in the team leader role, sticker on, role identified, and she left and walked out. And the team continued and the resuscitation continued, and then she dropped back in to the debrief organized by the department and some senior nurses. And had the absolute vulnerability to say that she had to step out because the child who came in was wearing the same shoes that she sent her daughter to school in that morning that she put on a couple of hours ago. And so, she was saying it just hit too close to home for her and so she just removed herself from it.

MIC CAVAZZINI:               I'm welling up just hearing about that.

JOSEPHINE GOODYER: Yeah. And then had the absolute professionalism, strength and vulnerability to be able to come back in and share that.

MIC CAVAZZINI:               Have you ever heard of the kind of debriefing or counselling that can help reduce that emotional. I guess What I'm thinking is, rather than debriefing, is pre-briefing. Within that transition program back to work, even one conversation that says, “Look, this is a scenario that you might encounter. This is how it's going to make you feel. And you probably can't train someone to shut that out completely but yeah, “if you do feel overwhelmed by this, here's what you can tap out and get support, to excuse yourself.”

JOSEPHINE GOODYER:  Yeah, and I don't know that we do that in workplaces or training settings in Australia in a formal way. I do know that we have discussions about it or start conversations about it within the workshop. And that's part of the intent around it, I guess, just to try and create some visibility and to try and provide, I guess, an anticipatory form of normalization. Like it's completely expected that if this is something you experience, you'll have an emotional reaction to it.

MIC CAVAZZINI:               It doesn't make you unprofessional.

JOSEPHINE GOODYER:  Absolutely not, yeah, it makes you human.

MIC CAVAZZINI:               That was Dr Josephine Goodyer ending this episode of Pomegranate Health. Many thanks also to Dr Sasha Symonds and Renee Byrne for inviting me along to the PRAM workshop they’ve developed with so much care. And most of all, I’m grateful to all the participants you heard from for allowing us to listen in to their moments of vulnerability. You heard from Elodie, Eliza, Emma, April, Stephanie, Lucy, Paula and also in attendance were Petrisse, Anika and Clare. Further staff support was provided by nurses Jane and Carolyn and technician Nour.

I’ll put a link to Kids Simulation Australia in the show notes, where you should be able to find information about the next PRAM course in Sydney. You can also Google for Paediatric Returnees After Maternity or Extended Leave. At Royal Melbourne Hospital there’s a similar workshop called CRASH for Critical Care, Resuscitation and Airway Skills in High Fidelity Simulation.

In the next podcast episode we’re going to hear from anaesthetics Professor Kara Allen about what the eight years experience of that program has revealed about the barriers and facilitators for returning medics. Also joining me will be paediatrician Dr Jenny Proimos, who has an academic interest with the Advancing Women in Healthcare Leadership initiative. We’ll be discussing the gendered impact that childrearing has on medical careers and what might be some levers in workplaces, policy and relationships that could help minimize this. 

Go to our website racp.edu.au/podcast for links, readings and other resources. There you’ll also find thanks to the music composers you’ve heard and each member of the podcast review group who helped with early drafts of this story. I’m Mic Cavazzini. You can write to me with your feedback and ideas via the address podcast@racp.edu.au.

This podcast was produced on the lands of the Gadigal clans of the Yura Nation. I pay respect to the mothers from 400 generations or more. Thanks for listening.