Asking for senior intervention : conceptual insights into the judgement of risk by junior doctors

Abstract

Drawing on a Grounded Theory approach, this interpretivist study explores the multiple influences on a pre-registration house officer's (PRHOs) response to a judgement call within a clinical setting. The study aim was to generate a conceptual understanding of judgement in a 'risky' situation and reflected this researcher's dissatisfaction with explanations in the medical literature about how clinicians think about 'risk' in practice. In a phased approach to data collection (Phase One n=32, Phase Two n=21) semi-structured interviews were conducted with individual PRHOs. A third phase developed the emerging theory. The PRHOs needed to recognise and weigh up, amongst a myriad of identified 'risks', those that had clinical relevance. One such judgement was whether or not to gain senior intervention. The factors mediating this judgement were: tenets that needed to be balanced to ensure safe practice within a training context ('act responsibly' and 'progress and develop') and estimating the chance and severity of potential consequences, not only to the patient, but to himself and the team. What was needed to make these judgements was knowledge of the patient's condition, one's ability to understand and manage the situation, and recognition of contextually meaningful cues. A perceived lack of knowledge or understanding was also influential. The PRHOs' judgement of 'risk' was a dynamic process, akin to a heavily ornate mobile with interconnecting elements and exemplified by the need to create counterbalances between multiple consequences. No prescribed action could have allowed the PRHOs to deal with the multiple configurations that they faced and needed to take into account. It is argued that judging whether it was appropriate to contact a senior, mirrored essential attributes for clinical practice: an independent yet co-operative and discerning practitioner who was able to balance multiple considerations whilst ensuring patient care. The PRHOs were practising what they needed to become.