Investigation – by any Other Name?

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Every cloud has a silver lining. I have had the misfortune (good fortune?) to have surgery four times since July 2017. Pain and inconvenience aside, and I am well on the way to complete recovery now, it was an unexpected opportunity (and pleasure) to observe another sector in action. Many times daily I had the opportunity to watch nursing staff deploy technical skills with emotional intelligence and dexterity, employ controls, carry out briefings or emergency response, faultlessly, all the while following procedures to the letter. Woe betide anyone who interrupted or distracted the pair in high-vis labelled tabards doing a drug round. And my identity was checked relentlessly every single time. The ‘buddy system’ was automatic. Undervalued? You bet. And their shifts were very long. But their safety culture was alive and well (in three separate hospitals!).

I also had the good fortune to have had the attention of two excellent surgeons who have proved to be technically outstanding. But as one who teaches investigation, it was their humanity combined with diagnostic skill that impressed. In my teaching, it is noticed by myself and my colleagues how difficult many, even very senior people, find data collection because they don’t seem to be able to drill down with their questions; they cannot extrapolate from one question to the obvious next one leading from that. This inability hampers many an investigation; things get missed.

But these two surgeons could not be faulted. They knew that they needed as much information as they could wring from me before I was under anaesthetic and they were on their own. It was Incident Investigation (Diagnostics) at its very best! None of the procedures were simple or repetition of what had gone before. The first did not even have a scan to go on because it was soft tissue being operated on. The neurosurgeon dealing with my back clearly was thinking about the problem all the time; he was inclined to phone me at odd times to ask more questions he had thought of. ‘Give me a picture of what it feels like’, which I did. This metaphor really worked for me.

What most impressed me, though, was the lack of ‘I am right’, the overweening certainty that is much around. The first back surgery was a success. But then, shortly, the other side came into play. He couldn’t understand why he had missed it. Should he have seen anything? More questions. The scan showed nothing. Might it be a latent malignancy? Another visit to theatre it had to be. And ‘Eureka!’ A small cyst, which must have been very tiny at the first surgery, had grown and was lying on the nerve. The remedy was just snipping it off!

What interested me was this eminent man’s ability to entertain the existence of two separate unrelated failures, to not hang on to the notion that he had fixed the problem, and to keep on fact-finding until he felt justified in opening my back again. He did not know what he would find after all.

It illustrated to me what we always teach: that investigation (or diagnosis) is problem solving, and that jumping to conclusions, being convinced of your rectitude, saying ‘I am right’ or ‘I am the expert’, just never works. More than a small measure of humility is needed if you are going to see the big picture, entertain that it might be something else as well, ask the right questions, drill down, not make assumptions and listen to others – the patient in this case, or the person who was involved in an incident. Above all, we must listen.

The satisfaction in eventually getting there, fixing it, maybe saving lives, in both instances, outweighs any hollow victory of masquerading as the ‘expert.’

And remember, exploring good practice in other sectors and professions is rewarding and teaches much. Everyone needs to keep learning.

“When you think you have exhausted all the possibilities, remember this, you haven’t!’ Thomas Edison

Lorna Ramsay