Many doctors say they are leaving training without the confidence to make high-stakes decisions, as increasingly consultant-delivered care limits opportunities to take responsibility for clinical risk, a new paper from the UK’s Academy of Medical Royal Colleges suggests.

Here Dr Jeanette Dickson, a consultant clinical oncologist at Mount Vernon Cancer Centre in Hertfordshire, Chair of Council at the academy and one of the paper’s authors, discusses why health educators see risk management as an increasingly vital area of focus.

Dr Jeanette Dickson, Source: AORMC

What was the main catalyst for the paper?

When we undertook medical education training reform, phase one was a diagnostic looking at postgraduate training. In speaking with our resident colleagues, many felt let down by their training, and we had detailed discussions about why they were uncomfortable. Some of it was pay, or the feeling of being moved around too much or being undervalued. But some of it was about feeling unprepared. 

Reflecting on my own training, there were definitely too many hours and too little support. But we came to the conclusion that the feeling of unpreparedness isn’t because we’re not training well; it’s because we are not allowing resident doctors to exercise those skills. Over the past 10-15 years, service delivery has become increasingly consultant-delivered rather than consultant-led. While that’s positive for patient safety and patient outcomes, it means that many resident doctors don’t get the same opportunities to exercise higher-level skills of decision making and holding risk, which really go hand in hand. 

We’re very good at teaching tasks, knowledge and technical skills, but we’re not so good at teaching the integrative function of holding risk. That felt like an important gap to address.

The 10-year plan is very focused on curricular rewrites. If we’re going to rewrite curricula, it’s important to think about the cross-cutting capabilities that we need to include.

How can training better develop risk management skills given the reduced time available and more consultant-led care?

In postgraduate medical education, if you’re clear about what skills and decisions you’re talking about, you can then think about how to assess them – be it through workplace-based assessments, exams, or both. Much of the 10-year plan concerns reforming the way we work, which will change patient pathways, and with that, the points at which risks are held could shift.

When it comes to decision-making and risk-holding, we need to ask, does it have to be a consultant? Could it be a senior, experienced resident? Or somebody who’s a “senior decision maker”, assessed to have the necessary skills to take certain decisions with minimal supervision?

Is risk-holding linked to diagnosis or certain specialties?

Our discussions [in the paper] include the systematic teaching of risk throughout a clinician’s career. That means being explicit about what we expect at each stage and telling resident colleagues: this is the level of risk you should be holding. Residents should be challenging themselves to hold that risk and learn to feel comfortable with it. 

Every specialty holds risk, but in slightly different ways. Take general practice, for example – they will be holding a lot of risk because they see undifferentiated patients and make diagnoses often without immediate tests. They act as gatekeepers to secondary care services, and must decide who to let through the gate. You can’t just let everyone through and you can’t block everyone either, good risk holding is finding the right balance. General practice tends to teach this skill more explicitly, but they are not the only specialty where risk is significant.

In hospital, I have access to blood tests and the x-rays, so the risk is not just in the diagnosis. It’s also about over-diagnosis and under-diagnosis, or deciding whether an illness is self-limiting or requires urgent specialist intervention. 

As an oncologist, my role is to discuss the evidence for a patient’s treatment, assess whether it can be delivered safely and appropriately, and consider the patient’s preferences. Another key risk we take is talking to patients about stopping treatment, and navigating end-of-life care decisions.

How can we tackle fear of litigation and disciplinary action to enable better risk holding?

We know we’re doing much better as clinicians than ever done. Technology is advancing, drugs are advancing, the skill set is advancing – and we can do a lot more for patients. But with that comes an expectation from society that we will do more and it will always work. There’s a growing expectation that medicine – and doctors’ interventions – will always produce the best outcome. Often they do, but it’s not guaranteed. 

The inherent risks in health care have not really been discussed with the public in a coherent fashion. We tell people they are entitled to receive safe care, but safe care doesn’t mean that there is no risk. It doesn’t mean nothing will go wrong, and even if something does, it might not be the fault of one person. How do we strike a balance between saying, this is a recognised complication that can happen, even if everything is done well, and this is an error? Poor outcomes don’t automatically mean poor care.

What are the next steps?

One of our National Medical Leadership Fellows, a resident, has launched a survey of trainees and early-career consultants. The survey asks whether they feel they were trained systematically in risk, and whether they feel well-prepared, and what could be done differently in training to prepare residents better to practice independently, whether as GPs or consultants. 

I am also speaking with clinical pathway groups in NHS England about decision-making ability, and how it can be embedded throughout a clinician’s career. It’s really about how you train people to make decisions appropriately. They need to learn in an environment where they can fail safely, with support. We’re looking for opportunities to make that happen and encourage the system to use them, ensuring that decisions don’t automatically default to a consultant, but to someone with the competence to hold the risk required for that clinical situation. 

The full paper is available [here].