The Essential Handbook for GP
Training & Education
let’s do a little reading…
Transforming practice with RDM-p
Ramesh Mehay
TPD (Bradford)
Transformative change
Alters the culture of the institution by changing underlying
assumptions and overt institutional behaviors, processes, and
structures.
• It is deep and pervasive, affecting the whole institution
• It is intentional
• It occurs over time
Aims & Objectives
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An overview of RDMp and SKIPE
Really understand what each domain means.
Help you understand and categorise evidential statements
Help you apply the approach to different contexts
Hook you in! This stuff will change you!
Why bother with RDM-p?
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Far too often we think of decisions as ok or not okay
But decision making is a process, not an event.
Far too we look at the outcome rather than the process
RDMp starts with the process
And therefore helps you make decisions better.
Apophenia
seeing meaningful patterns or connections in random or
meaningless data.
We make premature judgements from just
a few bits of information
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“Perhaps she’s not managing with being a new mum”
“He’s clearly lazy and needs to pull his finger out”
“She’s a bit thick and needs to read a bit more”
“It’s because of his language and culture”
 YOU MAY BE BARKING UP THE WRONG TREE!
But System 1 thinking can be wrong!
What’s this?
Humans make decisions by
Small number of variables
+
Allocate value to those variables
+
Time frame
=
DECISION
We jump to conclusions and rush to ‘fix’
the problem – which fails to do the trick!
Click centre to play video
To make decisions BETTER
Probably more helpful to think about HOW we go about making
decisions
rather than
WHAT decision should we make or has been made
And that means…
We need to gather comprehensive ‘all rounded’ information:
• From the trainee
• From things you already know
• From talking to others: colleagues, trainers, other docs and
patients (+other stakeholders).
Please find a piece of paper and a pen
• A list of words follows
• Look at them once, do not re-read them
• When you have read the list close your eyes
Flange
Route master
Laggard
Sausages
Automaton
Approach
Antichrist
Research
Slipper
Haggle
Fridge
Locomotive
Bracket
Confused
Telesales
Professor
Stool pigeon
Hale
Banquet
Irrelevance
Write down as many words
as you can remember
A
B
C
D
E
Flange
Routemaster
Laggard
Sausages
Automaton
Approach
Antichrist
Research
Slipper
Haggle
Fridge
Locomotive
Bracket
Confused
Telesales
Professor
Stool pigeon
Hale
Banquet
Irrelevance
How many words
that you remembered
are in each group?
• How many words did you remember?
• How many did not exactly match the words on the list?
• What does all of this mean for us?
Daniel Kahneman
Economics
2002
Dual Process theory
System 1 = intuitive; System 2 = analytic
System 1 thinking (intuitive) – what’s the
diagnosis?
System 1 thinking – Diagnosis & Treatment
Diagnosis
Rx
System 2 thinking (analytic)
• 85 year old with a raised cholesterol and who is hypertensive
but prefers not to go on statins. She’d like to know what you
think though.
• What next?
With the trainee in difficulty
• We often go for system 1 thinking
• We should be going for system 2 thinking
 STOP, BLINK & THINK
Dwivedi G, et al. BMJ 2006; 332: 406
• Mrs Patel; R chest pain.
• 28 years old, 7 month old baby.
• Pain started 2 months ago, well localised over the R chest
wall with no radiation. Precipitated by pushing daughter in
pushchair
• Pain not exacerbated by deep inspiration, coughing or
twisting; no dyspnoea, palpitations or dizziness.
• Previous GP consultation = musculoskeletal pain.
• PMH: Type 2 diabetes 3 years, well controlled on oral
medication (HbA1c 7.5%); hypothryoidism, l-throxine
25micrograms daily
• BMI 34.6
Dwivedi G, et al. BMJ 2006; 332: 406
• Mr Patel; R chest pain.
• 65 years old
• Pain started 2 months ago, well localised over the R chest
wall with no radiation. Precipitated by pushing
granddaughter in pushchair
• Pain not exacerbated by deep inspiration, coughing or
twisting; no dyspnoea, palpitations or dizziness.
• Previous GP consultation = musculoskeletal pain.
• PMH: Type 2 diabetes 3 years, well controlled on oral
medication (HbA1c 7.5%); hypothryoidism, l-throxine
25micrograms daily
• BMI 34.6
Dwivedi G, et al. BMJ 2006; 332: 406
• Mrs Patel; R chest pain.
• 28 years old, 7 month old baby.
• Pain started 2 months ago, well localised over the R chest
wall with no radiation. Precipitated by pushing daughter in
pushchair
• Pain not exacerbated by deep inspiration, coughing or
twisting; no dyspnoea, palpitations or dizziness.
• Previous GP consultation = musculoskeletal pain.
• PMH: Type 2 diabetes 3 years, well controlled on oral
medication (HbA1c 7.5%); hypothryoidism, l-throxine
25micrograms daily
• BMI 34.6
Who knows the story of
Noah in the Bible?
Imagine you are working as a doctor in a remote village. It’s the
weekend. There are no other health care professionals around.
But you do have a new piece of technology called THE
MARVELTRON
• The MARVELTRON will save the life of any patient you are
treating.
• But you have to answer correctly the question the
MARVELTRON asks of the attending doctor before it works
its magic.
• A young child is brought to you. She is seriously ill and will die
imminently.
• You switch on the MARVELTRON and await the question.
• You must write down your answer immediately the question
is asked, or the child will die.
• You will be blamed for the patient’s death only if you do not
write down an answer. No blame will be attached to you if you
get the answer wrong.
• ARE YOU READY?
• Have you got paper and something to write with?
• According to the Bible, how many giraffes did Noah take
into the Ark?
Answer quickly
Write it down
The child is dying.
How many giraffes?
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0
1
2
3
4
5
6
7
More than 7
The correct answer
• Of every clean beast thou shalt take to thee by sevens, the male
and his female: and of beasts that are not clean by two, the
male and his female. Of fowls also of the air by sevens, the male
and the female; to keep seed alive upon the face of all the earth.
Genesis. Ch 7
• Whatsoever parteth the hoof, and is cloven-footed, and cheweth
the cud, among the beasts, that shall ye eat.
Leviticus Ch 11
• Where did you get the information from to make the
decision about Noah and the giraffes?
• If you had had time, what would you have done to make
sure you had the right answer?
So what am I trying to say?
• We need to be careful of jumping to conclusions or relying on
our ‘hunches’
• With familiar situations, just stop to pause and think for a
moment to ensure you’ve considered alternatives.
• With the unfamiliar - check things out properly. Data gather
comprehensively and triangulate pieces of evidence against
other pieces of evidence. Look for themes
And RDM-p helps you do just that.
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It represents all aspects of our work
Comprehensive collection of data
Triangulates different bits of evidence
Helps you make sense of that data
Provides a framework with which to explore things with the
trainee.
Six Quick Questions
Please find a piece of paper and write down your answers to
each of these six questions
You have about 10 seconds for each response
On a fire engine, there are 2 drivers up front, one at the rear
and four additional fire-fighters.
What is the total personnel required for 5 standard trucks?
How many turtle doves did my true love send me on the 2nd
day of Christmas?
In 2008, the average time required to complete a root cause
analysis was 15½ hours, how much time should be allowed
for the three that are expected next month?
A bat and a ball cost £1.10 in total. The bat costs £1.00 more
than the ball.
How much does the ball cost?
If it takes 5 machines 5 minutes to make 5 widgets, how long
would it take 100 machines to make 100 widgets?
In a lake, there is a patch of lily pads. Every day, the patch
doubles in size.
If it takes 48 days for the patch to cover the entire lake, how
long would it take for the patch to cover half the lake?
Answers
A. 35
B. 2
C. 46½ hours
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D. The ball costs 5p and the bat £1.05
E. 5 minutes
F. 47 days