to call or not to call: a judgement of risk by pre-registration house officers

To call or not to call: a judgement of risk bypre-registration house officersJane Stewart

OBJECTIVES This study set out to answer the followingquestions. What influences a junior doctor�s responseto a judgement call within a clinical setting? What, ifany, are the relationships between these influences?

METHODS This paper describes an interpretivist studybased on a grounded theory approach to dataanalysis. This involved a phased approach to datacollection using semi-structured interviews. Analysiswas facilitated by observations and group presenta-tions. Participants were doctors in their first year ofpostgraduate practice who were purposively selectedfrom a range of hospitals in the Northern Deanery.

RESULTS The data demonstrated a number ofinfluences on whether junior doctors chose to seeksenior assistance. These included the upholding andbalancing of tenets that were necessary for ensuringsafe practice, and estimating the chance and severityof potential negative consequences to patients,themselves and their teams. In order to make thesejudgements, junior doctors drew on different formsof knowledge, especially knowledge gained fromprevious clinical experiences. In judging whether ornot to contact a senior, pre-registration house officers(PRHOs) were practising essential clinical attributes,that of independent yet co-operative and discerningpractitioners who are able to balance multipleconsiderations while ensuring patient care.

CONCLUSIONS This particular judgement of risk, as itwas described by those interviewed, was a dynamicprocess exemplified by the need to create counter-balances between multiple consequences. As a result,no prescriptive action could have allowed PRHOs to

deal with the numerous configurations they facedand took into account.

KEYWORDS humans; medical staff, hospital ⁄ *psychology;education, medical, graduate ⁄ *methods; *judgement; clinicalcompetence ⁄ *standards; multicentre study [publication type];risk factors; risk assessment; England.

Medical Education 2008; 42: 938–944doi:10.1111/j.1365-2923.2008.03123.x

INTRODUCTION

Arguably, the ability to know when to contact a senioris at the very foundation of safe clinical practice fordoctors in training. It ensures that patient safety ismaintained while junior clinicians gain meaningfulexposure to, and experience of, managing anddelivering care.1 Despite its importance withinmedical training, the act of contacting a senior hasnot been investigated systematically.

The study described in this paper emerged from myinterest in how doctors in their first year ofpostgraduate practice (pre-registration house officers[PRHOs]) recognised some clinical situations as�risky� and others as unproblematic2 and fromdissatisfaction with the linear rationales of algorithmsand fault-trees (for example, see Evans3). I wasinterested in understanding the complexity ofmaking judgements within the practice context andin developing a conceptualisation of the messy(rather than the sanitised) world of clinical work. Therationale for studying how junior doctors might judgesomething to be a risk arose from the belief that asituation thought of as risky would be acted upon.4,5

By understanding how junior doctors conceptualisedrisk, we might gain valuable insights into whatgoverns their actions.

Conducted in three phases, this study set out toanswer the following questions: what influences aPRHO�s response to a judgement call within a clinical

accreditation

School of Medical Education Development, Newcastle University,Newcastle upon Tyne, UK

Correspondence: Jane Stewart, School of Medical EducationDevelopment, Newcastle University, Framlington Place, Newcastleupon Tyne NE2 4HH, UK. Tel: 00 44 191 246 4524;Fax: 00 44 191 222 5016; E-mail: [email protected]

938 ª Blackwell Publishing Ltd 2008. MEDICAL EDUCATION 2008; 42: 938–944

setting and what, if any, are the relationships betweenthese influences? The first phase, not describedhere, explored the risks of practice with PRHOs.This identified the act of calling a senior doctor forassistance as representative of a situation where thePRHO recognised �risks�.6 This paper describes thefindings from Phases 2 and 3 of this larger study,which looked at the judgement involved in decidingwhether or not to contact a senior.

The study took place when the norm for postgraduatepre-registration training in the UK was two 6-monthplacements in surgery and medicine.

Methodology and theoretical stance

The epistemological position adopted was construc-tionism7 and the research paradigm interpretivism.8,9

These stances are evident in the following rationale.

In order to capture authentic representationsof practice, the phenomenon of �risk� and itsjudgement were not imposed but allowed to emergefrom clinicians� accounts. Ultimately, any story canonly ever be partly illustrative of reality, but storiesmay represent many of the hidden aspects of life thatcan only be made explicit and captured through the

teller�s descriptions.10–13 Clinicians� stories representconstructed versions of practice which tell of thevalues and judgements that underpin their clinicalwork. When analysing these multiple accounts, theresearcher needs to deconstruct each of the storiesand then reconstruct them to give a collectiverepresentation of a described reality.7–9

The study followed the traditions of grounded theoryfor the purposes of analysis,14 but my intention wasonly to develop a conceptual understanding of thejudgements involved in contacting a senior, ratherthan to generate substantive theory.15 The study wasdesigned in phases so that the focus for the investi-gation was built from previous phases of analysis andallowed PRHO responses to direct the subsequentphase.

METHODS

Data were collected via interview. Early interviewsexamined organisational structures using pre-pre-pared questions. Some exploratory questioning wasalso used. Later interviews reversed this trend so thatexploratory questioning was used predominately.This shift allowed formal, procedural structures to beidentified before rich descriptions were added.16,17

All interviews were audiotaped and transcribed.Analysis was facilitated by the computer programmeNUD.IST.18

Analysis began by open coding, which included sortingand labelling the data by content and placing theseinto categories. The categories were then furthersubdivided and sorted by writing summary accounts ofthe contents, re-sorting and then, where appropriate,devising diagrams which gave schematic representa-tions of the new category. When a diagram wasproduced, the category was revisited to ensure that thediagrams correlated with the transcripts and allaspects were included. Summary comments weremade about each category and included descriptionsof what the data appeared to indicate.19,20 Notesand summaries were kept so that development inconceptualisations could be mapped. These processesallowed patterns to emerge from the data whileensuring an accurate representation of the transcripts.

All diagrams and summaries were then consideredrelative to one another. This created further modifi-cations of the categories and diagrams. In eachinstance the transcriptions were re-reviewed, ensuringthat any new conceptualisations still represented theinterview data. This method of analysis and the

Overview

What is already known on this subject

Although there are countless studies on decisionmaking and risk assessment, little attention hasbeen paid to how junior clinicians judge thecomplex situations they face on a daily basis.The act of �asking for senior assistance� has notbeen studied systematically.

What this study adds

The conceptual model presented here explainsthe complexity of this prosaic act and providesan alternative way of thinking about clinicalpractice, which differs from the algorithmic andprescriptive versions of practice that are soprevalent within the literature.

Suggestions for further research

Further insights could be gained about practiceand clinical knowledge by deconstructing other�commonplace� medical activities.

ª Blackwell Publishing Ltd 2008. MEDICAL EDUCATION 2008; 42: 938–944 939

PRHOs� judgement of risk

diagrammatical representation allowed interconnec-tions to be captured. It also allowed establishedsystems and processes to emerge and be mapped,along with the reasons why they were not followed oradhered to by the PRHOs.

Throughout the analysis, constant comparativeanalysis was conducted by systematically reviewing thetranscripts to expose data that contradicted orchallenged emerging conceptualisations. Thisanalysis process was supported by 36 hours of non-participant observation plus six 1-hour presentationsto PRHOs, in which the emergent findings weredescribed. Undertaken when the interview data werebeing analysed, the observations and presentationsensured that my interpretations of the interview datawere continually appraised and my assumptionschallenged by what was being observed or describedby PRHOs.

Sampling

The interviews used a purposive sample of PRHOsdrawn from hospitals within North East England(Phase 2, n = 21), including a large teaching hospital,a large general hospital, a medium-sized general

hospital and a small district hospital. Clinical tutorswere asked to submit names of PRHOs in samplesthat represented a mix of genders and specialtiesand included PRHOs who were judged to workeffectively at that grade.

The observations and group presentations wereperformed in hospitals that were not used for theinterviews. This meant that all hospitals within thedeanery were involved in the study and input wasgained from PRHOs at non-interview sites. Onlyone medium-sized hospital (the most common typein the deanery) took part in the observations; thedecision to recruit only one hospital for theobservations was made after considering the purposeof the observations (to facilitate the analysis ratherthan as a data source) and balancing this with theobtrusive nature of shadowing PRHOs.

The model

Under the headings of �Underlying principles�,�Consequences�, �Underpinning knowledge� and�Contributing factors� I will describe the basic featuresof the conceptual model (Fig. 1) devised from thisstudy. To conceptualise and understand the practice

Approachable senior

More desirable to contact

Less desirable

Effort needed tocontact

More

Less

No time to think

Valuable and reliable senior

Figure 1 Conceptual model


J Stewart

of asking for senior assistance, readers should thinkof this model of judgement as something akin to achild�s mobile: it contains influencing factors thatconstantly change, shift and affect one another. Themost important feature of the model (and ofmobiles) is how it creates and maintains its equilib-rium through counter-balancing competingdemands; this is essential to ensure the stability andcontinuity of its structure and, as argued here, toallow the PRHO to function in clinical practice. Thisconceptualisation therefore presents judgement as adynamic, complex cognitive process.

Underlying principles

Two principles emerged from the data. Thesereflect the values that needed to be upheld anddemonstrated by the PRHOs in clinical practice: actresponsibly when dealing with patients, and progressand develop towards independent practice. Themaintenance of these two principles draws attentionto the potential tension within a dual-role systemwhich requires PRHOs to deliver health care while intraining. For example, it was clear from the data thatthe PRHOs saw their responsibility to patient welfareas paramount and their own needs as subordinateto this, but they still needed to develop their skillswhile in a service situation. To create an environmentthat allowed the dual roles to co-exist required thePRHOs to create a balance between these roles and torecognise when one took precedence over the other.In order to do this, they needed to be discerning.

So what were the PRHOs balancing and discerningbetween?

Consequences

Pre-registration house officers were aware that theiractions, including inaction, had consequences.Generally, the more consequences they perceived,the sooner they would contact a senior doctor.Consequences were also gauged in terms of thechance of an adverse outcome and the potentialseverity of the outcome. For example, the PRHOswould contact a senior doctor more quickly ifmultiple events were happening simultaneously orthe presenting symptoms or underlying pathologyhad the potential, or looked likely, to cause death orirreparable harm.

Importantly, the consequences described by thePRHOs were not just about patients. Junior doctorsrecognised that their actions could impact on theteam, individual seniors or themselves. The inter-

relationship between the consequences and thepreviously described principles explains these multi-ple impacts. For example, if a PRHO were tocontact her seniors continuously, this would indicatethat she was not discerning between cases normanifesting an ability to �progress and develop�.Neither would she be taking into account theconsequences of this action for the team andtherefore other patients. As the PRHOs were relianton senior co-operation and help to �progress anddevelop� and maintain their �responsibility� to patientcare, their actions were tempered by a reluctance toalienate or antagonise their seniors by constantlycontacting them. For example, PRHOs would try,whenever possible, to avoid contacting senior doctorsat night because night contact might cause a senior tobe tired and potentially less effective the followingday. Moreover, by managing alone, the PRHOs couldtest and demonstrate to seniors (and to themselves)their progression and development. However, thePRHOs knew that if it turned out to be a �bad call�,their seniors were likely to pay increased attention tohow well they judged other situations and wouldbegin to scrutinise their performance.

Underpinning knowledge

Three broad knowledge types were identified fromthe data: codified, cultural and personalknowledge.21 These allowed the PRHOs to make thejudgements described previously.

Codified knowledge, or textbook knowledge, wasimportant within the first few months of practice andwhen faced with novel situations.

Cultural knowledge referred to the rules and conven-tions of the practice context. The PRHOs were able tojudge when rules were applied but not whether theywere applied. This was because the rules related topatient safety and were integral to �being responsible�.For example, a PRHO was able to decide when tocontact a senior, but the rule was that �seniors mustalways be kept informed�. Whereas rules were overt,conventions were not explicitly stated and, unlikerules, were not patient-oriented but were intended tofacilitate team working. As such, conventions couldbe ignored when they jeopardised or interfered withpatient care and the principle of �being responsible�.The conventions included: �contact the most imme-diate senior first� and �examine and assess the patientbefore asking for senior input�.

Personal knowledge, the knowledge gained fromworking within situations and hands-on experience,



gave the PRHO insight and an ability to judgesituations. Personal knowledge included informationon a particular patient�s condition, its likelyoutcomes, the way that particular ward worked, whatparticular seniors expected and whether the time ofday changed their expectations. Unlike codifiedknowledge, personal knowledge represented rich,contextualised knowledge that could be used toinform action in specific clinical situations.

The PRHO not only assessed whether she had thenecessary knowledge or skill to continue without asenior but, perhaps more importantly, her own abilityto know whether she had enough knowledge orinformation to make these judgements within anygiven context. The more assured the PRHO was inher understanding (and more so if this knowledgehad been generated from successful clinical experi-ences), the less likely it was that the PRHO wouldcontact a senior. This assuredness was expressed bystating one�s overall feelings of confidence.

Contributing factors

Contributory factors made contact with seniorsappear more or less desirable but only ever mediatedborderline situations. For example, seniors thoughtto be unskilled or intolerant might not be contacted.Contact was also less favourably viewed if effort wasrequired to track the senior down. In this instance,the time taken to contact a senior might be betterused by the PRHO to think through the situationand, relating this back to the underlying principles,demonstrate progression and development byfinding a solution for herself.

The data from this study illustrated the multiplicity offactors that junior clinicians must take into accountin their practice. Collectively, these factors formeda complex matrix of hazards, threats, losses andbenefits that PRHOs need to weigh up before theycan assess the consequences of any single act. Thedata also clearly signalled that this judgement drewnot just on PRHOs� knowledge of conditions andpatients, but was underpinned by the values andcodes of conduct expected of them as professionals.

DISCUSSION

This study presents a model which illustrates thecomplexity of a single clinical judgement – whetheror not to contact a senior. It also transposes thesupposition of Redelmeier et al.22 that �judgement is acomplement to but not a substitute for knowledge�.

From these findings, rather than being complemen-tary, judgement is essentially established as the actof deliberating and evaluating knowledge:deliberating upon its completeness and accuracy, andevaluating its applicability within a specific contextand its transferability to another situation or context,and appreciating the consequences of being wrong inany one of these. As such, knowledge underpinsjudgement.

For judging whether or not to call a senior, codifiedknowledge was considered less valuable and lessuseful to the PRHO than personal knowledge. Thiswas because the clinical situations that utilise codifiedknowledge present themselves as tangible, clearlydefined, uni-dimensional, stable and predictableproblems. The problems that required the PRHO tojudge whether to call were ill-defined or multi-faceted, where a multiplicity of consequences neededto be taken into account and weighed up – hencethe need for judgement. Rather than using algorith-mic processing, appropriately judging whether or notto call a senior required active discernment aboutwhat could and ought to happen. Contextually richpersonal knowledge, gained from the PRHOs�experiences, allowed them to do this.

Cultural knowledge was central in guiding PRHOsabout �what was the right thing to do� and wasreinforced by seniors who controlled aberrantbehaviour via sanctions for those who digressed (suchas being checked up on). Seniors were thereforeimportant for developing PRHO judgement becausethey gave the PRHOs tangible boundaries as towhat constituted �acceptable ⁄ unacceptable� practice.This developed from learning what seniors expected,knowing their preferred ways of working andunderstanding the standards to which PRHOs mustperform while working with seniors.

In terms of training, being able to contact someonemore senior was important as it allowed these PRHOsto experience a level of independence in theirpractice while ensuring patient safety was upheld.This controlled freedom gave PRHOs a sense ofresponsibility because they knew that their actionsmattered clinically and that they were accountable forthem. This idea is supported by Lave and Wenger�snotion of legitimate peripheral participation,13 andDouglas�23 description of how hierarchical systemsfunction explains why it works. The need to managemultiple and competing demands was instrumentalin making PRHOs consider the consequences of theiractions and in teaching them what �responsibility�means in a clinical context; as educationalist Paulo


J Stewart

Freire observed: �Responsibility cannot be acquiredintellectually, but only through experience�.24

For the above reasons, the conceptual model devel-oped from this study supports the view that judge-ment is nearer to the art than the science of thedecision-making process25 and involves a capacity forhumane as well as technical competence.26 It alsoexplains why the delivery of medical care in a trainingsetting needs to involve the cooperation of allpractitioners and, as such, clinical judgements areunlikely ever to take into account only the needs ofpatients. It may be that the complex interplaybetween the factors described also mirrors the attri-butes essential for clinical practice, which arereflected in an independent yet cooperative anddiscerning practitioner who is able to balance multi-ple considerations while ensuring the provision ofoptimal patient care. As such, in judging whether ornot to contact a senior, the PRHO was rehearsing forthe role she needed to take on.

The introduction of the �Modernising MedicalCareers� (MMC) initiative, implemented after thisstudy was conducted, was intended to mark �a shift inpostgraduate medical education from apprentice-style training�27 and to introduce shorter clinicalplacements, outcome-based programmes, definedcompetencies and specified assessments. The modelpresented in this paper therefore captures howclinical training worked before MMC. It is also basedon what the PRHOs were willing and able to disclosewhen interviewed. Because they use only PRHOperspectives, my findings cannot be said to characte-rise all practice or reflect �other� perspectives. What iscaptured is the PRHOs� conceptions of how theythought about situations and how they thought theyought to act – namely, their theories of action.28

I would argue that, despite these limitations andchanges to the post-registration year, these findingsreflect how practice is understood by clinicians.

My personal concerns about how the recent changesto the pre-registration year will impact on practice areas follows. With less time in practice, postgraduatesmay take longer to internalise and appreciate thesituation-specific cues for when to call a senior. This,in turn, may lead to prolonged dependence on thepart of �juniors� and place more strain on theirseniors. That the 6-month PRHO posts have beenreduced to a series of transient 12-week placementsmeans that individuals could potentially avoid takingresponsibility for what they do or don�t do and, bydoing so, potentially postpone developing theirabilities. It is also somewhat paradoxical that the

perceived value of gaining multiple and variedexperiences may shift doctors� attention away fromlearning about the clinical care of patients as precioustime is taken up with getting to know the routinesand conventions of different wards and the workpractices of a range of �significant others� (Melia29

describes similar issues with trainee nurses).

The model presented in this paper helps us appre-ciate the complexity of judgement and why anostensibly simple task such as deciding whether orwhen to contact a senior cannot be viewed purely asa discrete competence to be achieved and ticked offa list. Neither can it be thought of as yet another itemto be covered in the undergraduate curriculum,although the knowledge foundations to it areundoubtedly laid there: this judgement is developedand refined by prolonged and repeated exposure tothe clinical context and mediated through seniorsupport and intervention within that context.30 Byfailing to recognise the complexity of such processes,the profession is in danger of undervaluing the veryskills that take clinical practice beyond technicalcompetence.

Acknowledgements: Philip Marshall, John Spencer andGabrielle Greveson are thanked for their feedback on thispaper.Funding: this study was undertaken as a component ofpersonal development and was jointly funded by thePostgraduate Institute for Medicine and Dentistry,Newcastle upon Tyne (75%) and the author (25%).Conflicts of interest: none.

Ethical approval: this study was approved byNorthumberland Tyne & Wear Heath Authority (ref.2003 ⁄ 02).

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Received 16 October 2007; editorial comments to author24 January 2008; accepted for publication 6 March 2008


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to call or not to call: a judgement of risk by pre-registration house officers

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