‘Don’t hesitate to call’ –the underlyingassumptionsJane StewartSchool of Medical Education Development, Newcastle University, UK

In clinical practice, patientcare must be maintainedwhile junior doctors gain

experience. Traditionally, thisparticular aspect of patient safetyhas largely been addressed by the‘rule’ that juniors will ask a moresenior clinician for advice whenfaced with conditions and situa-tions they do not understand orare beyond their scope of prac-tice.1

It is perhaps the significantchanges to postgraduate medicaltraining2,3 in the UK over recentyears that have prompted the callfor patient safety to be an explicitmodular theme within undergra-duate training. Certainly, with somany modifications affecting theway that on-the-job training is

conducted, we need to scrutiniseafresh how this rule functions atthe operational level. I wouldargue that, as an important safetyprocedure, asking for help andadvice from a senior has inherentweaknesses that cannot be ad-dressed adequately by yet moreundergraduate or classroom-basedtraining. In this paper I willdescribe the assumptions under-pinning ‘calling for help’, andpose some questions that couldassist in addressing theseassumptions if tackled by seniorclinicians.

In this paper, the terms‘junior’ and ‘senior’ are used todenote a relationship betweentraining doctors, although someof the questions posed will

arguably only be applicable todoctors who lead a team.

METHODOLOGY

The findings described are drawnfrom a larger study that aimed toexplore what and how pre-regis-tration house officers (PRHOs;now called Foundation Year 1doctors – F1s) judged risk withintheir practice.4

For the study, a purposivesample was drawn from represen-tative hospitals within the NorthEast of England: a large teachinghospital, a large general hospital,a medium-sized hospital and asmall district hospital. ClinicalTutors were asked to submitnames of PRHOs who represented

We need toscrutinise

afresh how thisrule functions

Workplacelearning

6 � Blackwell Publishing Ltd 2007. THE CLINICAL TEACHER 2007; 4: 6–9

a mix of genders and specialtiesbut were judged as having noproblems affecting their ability towork at that grade; these PRHOswere sought because their workrepresented ‘acceptable’ practice.

Data were collected via inter-view. A semi-structured interviewschedule was used first, to gain anunderstanding of how asking forhelp and advice from a senioroperated within different con-texts. An in-depth interviewschedule was then used to explorein detail how decisions weremade.5,6 All interviews wererecorded on audio-tape and thentranscribed. Qualitative analysiswas undertaken and assisted by thecomputer programme NUD.IST.7

Of the 22 PRHOs given theopportunity to participate, 21agreed to take part in the study:12 males (57.1%) and 9 females

(42.9%); 10 of the PRHOs were inmedicine (47.6%) and 11 (52.4%)in surgery.

THE ASSUMPTIONSUNDERPINNING ‘CALLINGFOR HELP AND ADVICE’

Assumption 1: Juniors willcontact a senior when theyrecognise the need to do so.Some PRHOs described occasionswhen they made a decision not tocontact a senior even when they orthe patient might have benefitedfrom senior intervention, implyingthat the decision to contact wasnot based purely on recognising aneed. Making a decision to contacta senior was more complex thanmerely adhering to a simple rule(see Quote 1 in Figure 1).

The PRHOs took into accountthe difficulties senior colleagues

might have in helping them, aswell as the possible impact on thesenior colleague and on patientcare. Not to consider these as-pects would demonstrate a disre-gard for other patients and fortheir seniors’ well-being. Not sur-prisingly, the PRHOs were reluct-ant to call for help at night unlessthey were completely sure that afailure to call the senior colleaguewould result in adverse conse-quences.

The data suggested that thePRHOs considered each incidentof need, and the applicability ofasking for help on that occasion.Ultimately, they made theirjudgement in terms of patientwelfare, but also wanted to dem-onstrate support for their teamand to prove their competenceboth to themselves and to theirseniors. By managing alone, thePRHOs could demonstrate to sen-iors their ability to work inde-pendently (see Quote 2, Figure 1).

Questions

Do any members of yourteam give the impressionthat (a) they don’t want tobe disturbed or bothered byjuniors, or (b) the juniorsought not to be calling? Domore senior members ofyour team give juniorsboundaries to work within,or must juniors second-guess what is expected?

Juniors will pick up cues andwork out when it is acceptable tocontact particular seniors by theresponse they get when they call.What sort of signals do you sendyour junior(s)? Are you consis-tent?

Assumption 2: A senior memberof staff will respond if called.PRHOs told stories of difficult anduncooperative seniors who didnot respond when called (Quote 3,Figure 1).

Quote 1: (Referring to the senior) ‘They’re twenty-four hours on call and then the

whole day after, so you just try and avoid waking them up because sometimes

they’ve got a long day and the next day they’re in theatre all day, or something like

that. So if you can at all manage the patient then … don’t call them.’ (D21:365–369).

Quote 2: ‘You want the Registrar to arrive on the ward in the morning and for you to

have done A to Z, and you’ve done it.‘ (D18:77–79)

Quote 3: ‘It wasn’t so much that I didn’t trust his judgement, he was just lazy and you

couldn’t rely on him to come.’ (D19:478–479)

Quote 4: ‘It’s extremely... extremely difficult because we deem that the seniors have

got more experience and that just implies that they’re better, that they know how to

deal with things better, but that is not necessarily true….’ (B14:164–67)

Quote 5: ‘In surgery it’s a bit more difficult because they’re in theatre all the time and

you feel like you’re on your own ... Unless it was a surgical problem they wouldn’t

deal with it. They didn’t deal with any medical problems, they didn’t do things like

shortness of breath, nothing, chest pains, nothing, they couldn’t deal with anything

medical.’ (D16:304–310)

Quote 6: ‘... it’s a big problem for the senior staff as well, because obviously if you

get a very unconfident House Officer who’s calling you for everything, everything

under the sun, I’m sure it’ll get annoying. And you think well “Why can’t you sort this

out yourself?” Whereas if you’ve got a more confident House Officer who’ll sort out

the majority of things on their own, and just let you know later on, it’s obviously much

more beneficial for the senior staff.’ (B11:117–124)

Quote 7: ‘There is the risk of, if you’re too confident and you never call for help, you

can get into trouble. When I say “get into trouble” I mean get the patients in trouble,

and you can get them too sick before a senior gets there. So there’s a fine balance,

you’ve got to toe the line and get it just right.’ (B11:648–653).

Figure 1. Illustrative quotes (see text).

PRHOs werereluctant to callfor help at night

� Blackwell Publishing Ltd 2007. THE CLINICAL TEACHER 2007; 4: 6–9 7

The PRHOs also recognisedthat some seniors did notrespond because they were jud-ging the appropriateness of thePRHO’s request, or were priori-tising their own workload overthe PRHO’s. The PRHOs eventu-ally learned how to differentiatebetween these non-responsesfrom a senior, and how tomanage them.

Questions

Are there members of yourteam known to be unsup-portive/non-proactivewith juniors? If this is notknown, how does one findout?

There are perhaps only asmall number of uncooperative andunsupportive co-workers withinevery department, but they dowork for someone. Is it for you?

Assumption 3: The senior bringsadditional knowledge to asituation.All seniors had had greaterexperience and exposure to pa-tients than the PRHOs, thereforetheir opinions should have moreauthority than those of theirjuniors. In reality this was notalways felt to be the case (seeQuote 4, Figure 1).

Getting senior support in sur-gery at any time was reported tobe much more complex than in

medicine, because seniors werenot readily available on the wards.Furthermore, when contact wasachieved, the surgical seniormight not have been able to helppersonally if the patient requireda medical opinion (see Quote 5,Figure 1).

For the PRHOs, the seniors’greater clinical experience did notalways equate to them havingknowledge that was relevant toparticular patients, or to thePRHOs’ needs.

Questions

When inexperienced mid-dle-grade doctors replaceexperienced ones, aremechanisms put in placeto compensate for thedeskilling of your team? Ifworking on a surgicalward, do juniors (specific-ally PRHOs) have easyaccess to medical support?

Perhaps this is least evident toseniors because juniors will even-tually find someone to help themout. However, if a situation ofneed does arise, getting help fromthose who are not part of theimmediate team is both stressfuland time-consuming. Is this aproblem in your team? If so, howcould it be addressed?

Assumption 4: A junior has the‘right’ level of confidence.Calling for advice and helprequires that juniors are neitherover-confident (in workingbeyond their remit or abilities) orunder-confident (when decidingwhat to leave for someone else tomanage). Being under-confidentmeans that the PRHOs are tooreliant on others, specificallytheir seniors (see Quote 6, Figure1), but the over-confidentPRHOs are also known to causeproblems for seniors in termsof patient care (see Quote 7,Figure 1).

PRHOs toldstories of

difficult anduncooperative

seniors

juniors who lackconfidence needmore input from

seniors

8 � Blackwell Publishing Ltd 2007. THE CLINICAL TEACHER 2007; 4: 6–9

The juniors who lack confid-ence need more input from sen-iors. While this is expected atcertain times in the pre-registra-tion year, arguably, this level ofinput is not sustainable. Over-confidence might be perceived asless problematic (even desirable),because these doctors get the jobdone with the minimum of seniorintervention. ‘Desirable’ that is,until the over-confidence inter-feres with patient care. An under-confident junior puts pressure onthe supporting team, but an over-confident one has the potential tobe ‘unsafe’.

Questions

How do juniors knowwhat each senior expectsfrom them? How does oneinstil in a junior an‘appropriate’ level ofindependence?

Juniors will know about their‘bad’ decisions from the feedbackthey receive from seniors andfrom patient outcomes. However,the good, borderline or poordecision with no obviousdetrimental effects might not belearnt from, because these are lesslikely to be discussed. In theseinstances, juniors will drawtheir own conclusions. Howoften do you give clear feedbackabout juniors’ decisions, orgive them suggestions forimprovement?

CONCLUSION

Being able to engage a senior’shelp is crucial within a system oftraining that allows its juniors towork quasi-independently untilit is considered unsafe for themto do so. Although this is animportant safety mechanism, ithas few associated formal regula-tions, which is appropriate in thecircumstances. The complexity ofthe decisions being made and thevarious skill-mixes of the juniorsand seniors make formulaic solu-tions such as ‘when X happens, doY’ unhelpful. Clinical judgement isneeded to calculate when a seniorought to be contacted.

This judgement emerges frommonitoring patient patterns andoutcomes, and receiving feedbackon one’s actions: why decisionswere good as well as bad; andwhat one ought to take (or havetaken) into account, and why. Thejuniors’ sense of what constitutes‘appropriate’ action within a givencontext develops from the amal-gamation of their multipleencounters8 and gives them aconceptual framework for use infuture cases.

Currently, what is necessaryfor the ‘contacting a senior’ sys-tem to work, and for the assump-tions discussed in this paper to beaddressed, is that a ‘poor’ teammust at least be matched with a‘good’ junior, or a ‘poor’ juniormatched with a ‘good’ team. The

combination of a maverick juniorand a weak team has the potentialfor poor, ineffective training, butmore seriously, it is likely to be adisastrous combination in termsof patient safety.

My concern is that, because ofreduced clinical exposure result-ing from fewer working hours andshorter attachments via F1 pro-grammes, the development of thisclinically based skill will makejuniors dependent on their sen-iors for a longer period, which willin turn place a significant burdenon more senior staff. To helpmanage this situation, seniorstaff will need to be explicit withjuniors about their expectations.Doctors who have responsibilityfor other doctors need to engen-der supportive and collaborativeteam working because, as thesedata suggest, training whiledelivering health care does notoccur in a vacuum but relies onco-operative behaviour betweenjuniors and their seniors.

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How often doyou give clearfeedback aboutjuniors’decisions?

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