Complex decisions, shared; Dr Suzie Farrell & the Shared Decision Making clinic.

Realistic Medicine; What?Why?How?

Kate: Welcome to episode four of our Realistic Medicine podcast. I'm Kate Arrow. I'm an Anaesthetist in NHS Highland and today we've got Doctors Suzanne Farrell, who's an Anaesthetist and Intensive Care Consultant in NHS Lanarkshire. And Suzanne is going to share a little bit about her experience with Realistic Medicine. And we're going to have a bit of a focus on some work she's been doing setting up a shared decision making clinic. So, Suzanne, do you want to tell us a little bit about yourself?

Suzie: Hi, Kate. Thanks for having me. It's an absolute pleasure. Yes. I suppose the first thing I should say is, call me Suzie. Okay. I'm an Anaesthetist in Lanarkshire and also in Intensive Care, and I've been a consultant there for just over ten years. So I guess what's brought me to Realistic Medicine has been a kind of circuitous journey. But if we start off by saying that half of my working week is in high risk anesthetics and the other half is in intensive care, that gives me a kind of dichotomy in my job because I love talking, I'm a gab, I like patients, I love hearing their stories. And as you know, you do the same job. It's really difficult when half the time you're spending your work and caring for patients that are unconscious. So I have this desire to not just deliver high quality anaesthesia, but also to really engage with patients and as much as I can, I guess I started off doing a Monday vascular list. That was difficult because it meant I had to go and see my patients on a Sunday. I thought, that's not good. Like, you know, I don't want to go on Sunday and meet my patients at the last minute. But the kind of process evolved and I started bringing patients up the week before. Then I started involving the surgeon and said to the surgeon, listen, why don't we go and see the patient together? This is high risk stuff. Then I developed an interest in assessing high risk and what high risk actually means. I got funding. I managed to put in a business case and successfully got funding for cardiopulmonary exercise testing, which is one way of stratifying risk. So it kind of grew from there. And I think what I was trying to do was do the consent process better. But despite that, I just still had this sense that it wasn't enough. Although we were telling people what the risks were, it was almost when the decision was made for them. And I kind of got this. There was a few notable cases there's, a few patients that really stick in my mind over the years, but despite the risk assessment, having said, yeah, you know what? Probably good to go ahead, did badly or didn't do as well as I hoped they would. So I had this kind of growing idea that there might be a different way to do this. So literally, about seven years in, no part of a lie, I got this, itch. I had to go somewhere. Now my best friend says I've got itchy feet and my husband says that I've always got a project on the go. So despite having four children, I decided that the next project was going to be I was going to try and find another way of thinking and another way of looking at this particular group of patients who are very, very high risk for surgery. So I came across a job in New Zealand and I applied and I spoke to them and I said, listen, I want to come and work for you, because they were looking for a locum, really. But what I wanted to do was join a clinic that they had already established there and they had this clinic model that they called 'Complex Decision Path'. So I started trying to line up all the docs and negotiate with my workplace to go away for not just the three months sabbatical that you earn after seven years as a consultant, but really to go that far, I wanted to be away for a year. So I had a lot of persuading to do. And NHS Lanarkshire supported me, ultimately, and going away turned out to be on the brink of a pandemic. So in January 2020, I dragged my husband and four children to the other side of the world just for a breath of fresh air and to try and see if there was a different way to do what I was doing. And oh, my goodness, what a great decision. So I participated in the clinic there, which was really different, really labor intensive. Instead of it just being a patient coming to see Anaesthetist face the fase, to discuss risks, they have two consultants. And I think that that's an expensive idea for the NHS. But actually I think it is so valuable, you'll know yourself, Kate, that Anaesthetists, like surgeons, have got different attitudes to risk. And I think the problem with a lot of high risk patients coming to see one anesthetist is that although one anesthetist might have a risk discussion with a patient and think, yes, okay to go ahead, we've discussed it all, we've been through the consent process. The patient comes on the day for someone different. So definitely there's two things I'm really not sure about this. So that creates a problem. Patients then can get cancelled on the day. They're deeply disappointed, the Anaesthetist on the day, feels uncomfortable, but bad for having to cancel the patient. So it has to be a better way to do this. That's why my clinic idea requires actually two consultants. There's one anesthetist and there's one intensive care specialist. So I think that turns it more into a multidisciplinary team instead of it being one Anaesthetist dependent. And it also definitely puts the patient at the heart of the multidisciplinary team. And the patient's family who come along with that is absolutely true. So I've spent the last year setting this up and it's running and now it's been funded. I can't believe it. I mean, honestly, everybody returning at the moment. We're told there's no money for anything and I've managed to present this to our board in September and meet our goal, and it's rewarding and I'm loving it.

Kate: How did you do it when you were still kind of on a shoestring, like when you weren't funded?

Suzie: Yeah, so when I came back from New Zealand,I had 4 hours a week. A job within a job was being advertised to be the realistic medicine deputy. So I applied for that and I got it. So I have used that time, if you like, to set up my clinic to do all the legwork and stuff. However, the people I really have to thank here are my two principal enablers actually set up the clinic. They've given me their time. So I've got one colleague who's about the equivalent amount of experience to me and works in intensive care as well, and one who does just anesthetics. And they have both come a lot. I've basically come back full of enthusiasm with this idea and said, listen, can you come and join me? Can you join me in this? And they've given me their time, really impressive time, whetn they're meant to be non clinical or recovering, in order to deliver this kind of labor intensive consultation. So it's been great. So. Thanks, Graham. Thanks Vanessa. Thanks so much for letting this happen, really. And we've done that for a year unfunded, so I've kind of counted it sort of in with the other stuff that I'm doing. But they have given their time for free. Very grateful.

Kate: Yeah. And so how has it gone down with the, I suppose I've got two questions; how do the patients find it? And how did you show the benefit, when you're so limited on time, in a way to get funding to prove it's worth?

Suzie: Patients love it. So really, when I presented all my data to the board, the two principal threads were when patients come to speak to us in a clinic like this and you really put them at the heart of the decision and allow them to realise that actually sometimes having a big operation isn't the right choice for them. If you allow them to realise that and they effectively opt out of having high risk surgery and choose to spend whatever time they have left. Now, this is hard. These are hard, hard conversations. Like you're asking someone who's got bowel cancer, for example, to consider the option of not having a...