On the backdrop of increasing ED wait times we have completely inept decisions by MOH @fordnation & @SylviaJonesMPP cutting MD hrs at St. Michael's Hospital @UnityHealthTO & other hospitals

Let's dig in 🧵
1/

@HumanFact0rz @davidcarr333 @raghu_venugopal
cp24.com/photos/2025/06… First, what do I mean by MD hours?

This isn't the amount MD's get paid. There's no $$ benefit to us having more hrs.

This is the number of hrs of MD coverage the govt funds within the ED. E.g. we have ~100hrs of MD coverage in our ED. We divide this over 12 shifts/day.

2/

I've started teaching my daughter effective learning techniques. Here's what the evidence tells us

Best: practice testing, distributed practice

Moderate: self-explanation, interleaved practice, elab interrogation

Worst: summarizing, highlighting, rereading, mnemonics

🧵
1/ I'll briefly mention the techniques that I utilize and teach

1. Distributed practice - spreading out study activities over time
- far more effective to study 1hr for 5 nights than 5hrs on 1 night
- this approach benefits long term retention
- basically cramming doesnt work!

2/

Make no mistake the recent words of the premier touting the strength of our healthcare system are not anchored in reality.

The many amazing healthcare workers battle a dysfunctional system to continue to deliver care despite the govt

Let me help the premier understand better
1/ Working in our current healthcare system is like running on treadmill with no end, no food, no water and the pace continues to increase. It’s not sustainable and eventually bad things happen.

What's the best way to practice to improve skill performance?

We studied this.


TL;DR – No difference betw deliberate practice vs self guided practice

BUT more efficient/faster 6months later for deliberate practice

My thoughts & reflections

A 🧵 https://t.co/qyorTESjqGrdcu.be/deI9l
First, we pulled off one of the largest randomized trials looking at practice in the #meded literature.

We enrolled 176 emergency medicine residents across North America at 5 sites. It was a huge undertaking and not an easy study to complete, esp the retention testing.

Starting March 31st @ONThealth announced they will purposefully & systematically reduce healthcare access to those who are marginalized or under resourced.

Ont govt will end a program that provided healthcare access to the uninsured.

Here’s a 🧵 on what this means.

1/ At first glance, this might seem to only affect visitors or travellers (which it will) however it will deliberately negatively impact many Ontario residents who have lost, can’t renew or have an expired OHIP card.

These are people who are in fact OHIP-eligible.

2/

In honour of upcoming St. Patrick’s Day and the luck of the Irish, here’s a post on the importance of luck in decision making.

What is luck? Well, it can be either good or bad and it’s the result of chance. By definition it's out of our control.

Here's a thread: 🧵
1/ Luck is a funny thing when it comes to decisions and our interpretation changes depending on who made the decision.

This week we saw an example of bad luck for clients of SVB. The bank run was completing out of their control.

2/

Every organization will encounter a crisis.

Here’s how we used the concept of pre-mortem to improve.

This week we @Sim_UnityHealth conducted a multi-disciplinary #simulation of a complete loss of IT infrastructure.

Goal: crash test our processes & ensure ongoing care

🧵

1/ Frequently organizations develop policies for crises but we know that work as imagined is never the same as work as done. @StevenShorrock

Orgs guess how ppl respond.

They hope ppl will remember the procedures.

They 🤞 that the system under stress will work.

2/

Many problematic "solutions" emerge from a top-down process that @StevenShorrock calls work-as-imagined solutioneering

A must read for healthcare leaders.

Unintended consequences, solutions waiting for a problem, compromises...

Some thoughts in a 🧵

humanisticsystems.com/2018/06/03/wor… Here's a story to start.

A few yrs ago, we needed to fix our massive hemorrhage protocol (getting blood to bleeding patients), due to frequent delays.

One issue was that RNs had to make 2 calls, one to the blood bank to get blood, another to get a porter

2/

All of us will be faced with high-stakes decisions in our lives but how can we approach these to optimize for the best outcome?

A set of tactics is key.

A thread 🧵

And for those looking for more info, check out this great paper.
1/
repository.upenn.edu/cgi/viewconten… First, what is a high-stakes decision?

1.Possibility of a large loss (e.g. financial, emotional etc)
2.Substantial costs to reverse a decision once made or impossible to reverse

E.g. buying a house, selling a company, having a risky surgery, etc

2/

The Thai Cave Rescue might be one of the most impressive examples of high stakes decision making & human performance in recent memory.

The exact details of what happened are truly amazing and warrant a deeper dive.

What can we learn from this unbelievable success story? 🧵
1/ Background: a soccer team of 12 boys and their coach became trapped 4km from the cave entrance.

The route to escape was flooded, some sections 15” wide, poor visibility and strong current.

2/

en.wikipedia.org/wiki/Tham_Luan…

The power of #simulation-informed #design

We tested, refined & improved the process for walk-in stroke patients using an 8 min scenario and 25min debriefing with a multidisciplinary team led by stroke NP Lee Barratt

A boardroom meeting never would've accomplished the same.

1/ We began with a pre-brief to discuss potential challenges and opportunities for improvement.

RNs, MDs, clinical assistants from ED and neurology all provided input.

Then, rather than guess whether these ideas worked, we went right to the clinical environment to test them.

2/

Massive Hemorrhage Protocol - Just the Facts @CJEMonline

We discussed 5 common questions related to MHPs. A short 🧵

Co-authors @winny_li & @HumanFact0rz

1/

link.springer.com/article/10.100… 1. Why do we call it an MHP now (instead of MTP)?

It may sound semantic, but it shifts priorities away from exclusively transfusion & towards a broader focus of controlling hemorrhage by:
- blood products
- normothermia
- TXA
- correct coagulopathy
- definitive hemostasis

2/

Massive Hemorrhage Protocol - A Practical Approach to the bleeding patient.

Amazing coauthors & world experts in MHP @JeannieCallum @LTEOLUZ & Katerina Pavenski

Here's a 🧵 summarizing our recent publication in @EMedClinics

Open access link below
authors.elsevier.com/a/1g7UE2ct6wsz…
1/ We followed the 7 Ts of the MHP (credit @ORBCoN1)
2/

A few reflections as I look around a dysfunctional healthcare system.

I see firsthand every day how terrible the situation is yet one of the unfortunate features of staffing a system with such resilient healthcare workers...is that it will never truly "collapse"...

🧵 it will just gradually deliver worse care.

And the inadequate access or poor care will never fully be visible to the public...nor will the public be aware of what all these amazing HCWs are truly capable of because we systemically impair their abilities

At the decision making workshop with @emergmedottawa, we discussed 8 specific ways to make better decisions.

Here’s a recap 🧵:

1/ 1.Reduce decisions when possible:

Design your system so that decisions don’t need to be made in the moment.

Ever try to eat healthy? It’s far easier at the beginning of the day than the end. Rather than rely on will power, ensure your environment supports your goals…
2/

Every day clinicians struggle with equipment, space and layout that encumbers, rather than helps them do their job.

A 🧵on how we applied human factors principles, usability testing & #simulation informed design to our new pediatric resus tower

1/ Our previous cart was a Broselow (color) based design. Lots of good human factors principles here but it's clear that even good HF intentions can be overcome when cluttered. Also the equip wasn't optimal.

Following design thinking principles, we began defining the problem
2/

Seeing multiple EDs across the province closing represents nothing short of a crisis.

These EDs and ICUs were built for a reason and to imagine we are now closing them despite rising volumes and demands leaves me speechless.

Here's a 🧵 on crisis management
1/ In my job as a trauma physician, I regularly face crises and manage uncertainty.

There are several key principles we teach in crisis management & decision making that would be helpful to apply to our HC system. I’ll outline 4 in the thread below.

2/

As a fellow emerg doc, I'm extremely disappointed to see this inaccurate focus on COVID related illness as the main cause for incr ED wait times and staff shortages.

Rather the link to COVID is that it exposed a system that has always been non functional, but now just more so.🧵

https://twitter.com/picardonhealth/status/1549800901681893376

This was an opportunity in a national magazine to help the public appreciate the current state of healthcare and the massive inefficiencies in the system...unfortunately this does little to advance the public understanding.

Here's a thread outlining the complexities.🧵

2/

We keep hearing how our healthcare system is collapsing (which it is). But that does nothing to improve our understanding.

Let’s use a hypothetical emergency department visit to highlight the disaster that is happening every day around the country.

Here’s a thread 🧵: 2/ Imagine you have abdominal pain. You make the decision to go emerg. You arrive by car and walk up to the doors.

You’re greeted by security.

Maybe you might find this uninviting for a hospital.

Well, these security guards are unfortunately necessary.

People ask me how is the emergency department these days, is there much #COVID19 anymore?

My observations below in a short🧵

TL/DR = the healthcare system is a disaster and it will be years before it improves...so buckle up.

1/ The short answer in my experience/observation is, no we're not overwhelmed with #covid19 patients requiring ICU level care in the hospitals.

But...that oversimplifies the current state. Let's look at it from the hospital, clinician and patient/family perspective...

2/

If you’re a leader and responsible for decision making in your organization, understanding the Cynefin framework is an absolute must.

Leadership requires modification based on the situation.

Here’s a brief 🧵 contextualized within #resuscitation & #healthcare
1/ Created by @snowded this 4 domain framework (5 with disorder) provides decision makers & leaders with a high-level yet practical approach to decision making by appraising the current state & developing an appropriate strategy

Great overview here.
2/
hbr.org/2007/11/a-lead…