Rubber Ducks

Having grown up in the 70s the words ‘Rubber Duck’ bring two cultural touchstones to my mind. The first is Ernie from Sesame Street who loved his Rubber Duck so much he wrote a song about him and the second is the film Convoy, starring Kris Kristofferson as the trucker known as Rubber Duck.


However, a recent tweet from the account of the QI Elves has added a new Rubber Duck to my consciousness and rather bizarrely it is related to my interest in Diagnostic Thinking. Is it possible that a rubber duck could reduce errors and improve patient safety?

QI Rubber Duck Tweet

As the tweet implies, when coders get stuck with their… err… coding, they are encouraged to carry out Rubber Duck Debugging – to talk, out loud, to a rubber duck on their desk telling it exactly what they are trying to achieve and how each line of code is supposed to work. The process of slowing down and explaining each step helps the coder clarify what they are trying to achieve and allows mistakes to be uncovered and corrected.


As clinicians we are becoming much better at thinking about our thinking. We try to understand how we synthesise a diagnosis from the information we have gathered whilst also being aware of the biases and shortcuts in our thinking that influence us, both for good and ill. However, this is usually about reflecting upon our actions after the event or spotting them in the thinking of others: trying to be aware of our own thoughts in real time as we work, is a much bigger challenge.

Nurse DuckSadly, much as I love educating clinicians about biases, this hasn’t shown evidence of real time error reduction in practice and efforts to get clinicians to slow down so they can use more deliberate cognitive strategies hasn’t really worked either. On the other hand, an intervention that has worked in reducing errors, is to get clinicians to pause and reflect upon the data they have and what they are trying to achieve. This reprocessing and reordering of the information appears to allow the clinician to improve diagnostic accuracy and make more appropriate management plans.


Now, if we stop and think about our working lives, this may not come as much of a surprise because this happens surreptitiously when we talk to a colleague about a difficult case, go to write our notes after seeing a patient or consider what we will say during a referral. The process of reorganising and re-examining our thoughts so that we can ask for advice, make a written record or hand a case over helps make things clearer in our own minds and uncovers omissions and assumptions in our thinking. For clinicians, Rubber Duck Debugging could be a way of formalising this process, recognising its value to us as a cognitive tool and teaching it to others.

Consultant DuckNow, I’m not actually calling for rubber ducks to be deployed in hospitals up and down the country (but if you want to, click here and you’ll find some AWESOME colleagues), however, I do think we have a responsibility to encourage clinicians to take time to reflect upon their cases early in their cognitive processes.Whether this is done alone, with a human colleague or by talking to a rubber duck, I don’t really mind, as long as it happens! It does appear to be a strategy that is useful at reducing errors and improving patient outcomes so surely that’s a responsibility we can’t… duck?


P.S. A rubber duck isn’t always the right answer though… sometimes, as Ernie himself discovered, we do have to Put Down the Duckie to achieve progress!


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