Authors: Nikki Abela / Editor: Liz Herrieven / Codes: SLO2, SLO7, SLO8 / Published: 16/07/2024

I was in a trainee meeting this week and one of my highly regarded colleagues reported that a particularly good trainee “never made a mistake”. He was saying it like it was a bad thing and it made me stop in my tracks: “Surely that’s a good thing, right?”

His reply: “It means she doesn’t know how to take risks”.

That got me thinking. Risk is something I think about a lot, and talk about a lot with trainees. I think a fundamental part of any trainee’s experience with us in the Emergency Department (ED) (be it a GP, FP doctor, ANP etc), should include learning about risk, how to find your own personal risk profile, that of the department you work in, and how to navigate the risky decisions we sometimes make.

Because we all know that we don’t want to be “that” medic, now or in the future, who refers or over-investigates every patient we see. But we also don’t want to be that doctor that makes decisions that harm our patients. Primum non nocere after all. It’s not just the oath of course, it’s those thoughts that keep you up at night worrying that you may have harmed your patient, caused an adverse event to someone who held you in a position of trust. At the end of the day, most of us became medics for the chance to do good.

“The only way you will not harm a patient, Nikki,” I remember one of my esteemed colleagues telling me, “is to not see patients. Realistically, the more patients you see, the more likely you are to make a mistake”. And that is very true. We have all seen it, senior colleagues who become paralysed in decision making due to the fear of making mistakes and causing harm.

So, how do we go about living with the risks we take and how do we teach this to our juniors?

First, I want you to think about your personal risk profile. Are you a big risk taker or someone who stays away from risk? There are benefits to both, of course. Big risk takers make bold decisions, do not heavily investigate their patients and potentially their patients have a shorter ED stay and are less likely to need an inpatient bed, among other things. They are, however, more likely to make mistakes. These people are liked by patient flow teams as their snappy decisions keep the department moving. They know they will get it wrong sometimes, and they are ok with that.

People who have a low risk profile (i.e. do not like to take risk), tend to use a more laborious process of decision making, are more likely to refer on to specialties and will be more likely to investigate patient symptoms. While they are less likely to make mistakes, they still may inadvertently cause harm through over investigation or treatment. These people are less popular with managerial/flow teams as their laborious thinking can “clog up” the department. They navigate only low probabilities of risk, and want to never miss an important diagnosis.

It is likely that most people lie in the middle of this spectrum. Junior medics will find that they, if given a chance, will seek the advice of senior colleagues with the risk profile most similar to theirs. Seniors sometimes fret that they are “shopping” for advice, but this is actually a medic trying to do what they consider right for their patient, with the back-up of someone they trust to make the right decision. Like it or not, a familiar risk profile is a sought-after characteristic in advice “shopping”.

It is important that you have insight into your risk profile for many reasons, including knowing that you are likely to get things wrong more or less often, sharing decision making with patients and their families, being aware that you may be over or under investigating or treating a patient, and knowing what effect this risk profile has on your leadership style and the department as a whole (for example, risk profile may change with workload – you are more likely to take the time to investigate thoroughly when there isn’t a 10 hour wait to be seen and perhaps less likely to refer to medics for a second opinion if the patient was going to wait hours for that opinion vs if they could get that in minutes).

The next thing I want you to think about is the risk profile of the department/trust you are working in. I am very lucky to work in two trusts, so I have the luxury to be able to observe and compare how different systems work. It is really important, professionally and personally, to only make decisions which will be backed by those around you and above you. If you are making decisions which do not have the backing of those around you and above you, you are navigating troubled waters and probably need to get advice about the job you are doing.

The last, and probably most important thing to talk about is how to navigate uncertainty. Now the team at St Emlyns’ have written a whole book about decision making here, which I very much suggest you read.

What I want to talk about is how to find mechanisms for you to be able to take risk, according to your risk profile (and that of your institution), and have it sit right with you at the end of the working day. This navigation journey may look different for different people (with different risk profiles), but that’s ok. There are several mechanisms you can employ to be able to make decisions, in a way that sits right with you, and those mechanisms look different for different clinicians, but also look different for a range of clinical scenarios.

Let me give you an example:

A registrar comes to me for advice after seeing an 18 year old patient with chest pain radiating to his scapular area, which is worse on lifting, lasted 3 minutes and has now gone away. The patient takes cocaine occasionally. The pain was not tearing, not maximal at onset. The pain has now gone away. ECG, CXR, FBC, U&Es, CRP and Trop are normal. Examination is normal except he has some thoracic tenderness to palpation. I look at the patient in the waiting area, he is not tall and slim and looks very well in himself. “Could this be a dissection?”

What mechanisms can you employ to navigate the risk that it might be a dissection?

  • You could do a CT aorta (somewhat invasive test, might not be easy to get, patient will be in the department at least 2 more hours).This is the gold standard – if negative you can go home and sleep soundly in the knowledge that the patient almost definitely has or does not have a dissection. You may also pick up some “incidentals”, which the patient will be treated for, which without the test he may not have known about or even needed, but that discussion is for another day.
  • You could do a d-dimer (not gold standard, you will still miss some dissections, but if negative, it makes it very much less likely). This is less invasive but also means a longer stay, and an even longer one if the test is positive (and then needs a CT aorta).
  • You can share that risk with a senior (like myself) and I can make the decision for you/or we can make the decision together – this is a highly suggested tactic when you are going against standard guidance and may be exposed as a maverick.
  • You can share the decision with the patient, explain the risk and see how he feels about further testing. It could be argued that this is the true gold standard.
  • You could feel confident that he doesn’t have a dissection, and just send him home. Plainly, easily, just like that.

As a senior clinician, I know this patient does not have a dissection. Call it gestalt or experience, but inside of me I just know. Or I know enough to realise that the odds are in my favour, and even if there is a slight chance I may be wrong, by problastician skills (as Simon Carley likes to call it) know that the probability is one I am comfortable with to send him home. I can’t teach gestalt and I can’t teach experience, but I can teach how to cope until you gain those things. Moreover, my acceptance of risk may not match up to that of my juniors.

“Whatever you choose, you may be right and you may be wrong. I will back you up whichever way it goes. Let me know what you want to do”.

Giving junior colleagues the opportunity for the buck to stop with them, with your backing, and talking them through the decisions they make is fundamental to teaching them risk. It will look different for different scenarios and different people, but it is important for them to learn to be able to live with risk, and how to cope with and make decisions which are vital to our specialty, and to them. Labelling it as a learning opportunity is important for them to recognise that this is a skill they are developing in their time with us and something they need to work on so that will serve them well wherever they end up in the future.