JRSM >
Volume 102, Number 11 >
Pp. 455
JRSM
What's your preference? Do you follow best practice? Or do you make clinical judgements based on the decision-making of your colleagues? Do you obey medicine's natural laws of hierarchy, etiquette and conformity? It is a tricky dilemma, especially for junior doctors who may be the most up-to-date but learn that their clinical team has a very different interpretation of the evidence. These competing influences can cause discomfort and may lead to poor outcomes.
Prescribing, for example, has been well studied in primary care but less well in a hospital setting. Penny Lewis and Mary Tully attempted to understand the impact of teamwork on prescribing decisions in hospitals, and their conclusions sound a warning for patient care (JRSM 2009;102:482–9). Prescribing is not always driven by therapeutic decisions alone, and hospital doctors’ decisions are strongly influenced by relationships with other team members, particularly nurses and senior doctors.
Critical incidents, described by doctors of varying grades, can be rooted in the difficulties of prescribing in a team environment, leading to sins of hierarchy, etiquette and conformity. Junior doctors felt discomfort when uncertain of seniors’ prescribing decisions, relating to the hierarchical structure of clinical teams. Prescribers followed the etiquette of medicine by maintaining the prescribing decisions of other doctors and other clinical teams. And they conformed by prescribing to maintain overall team relationships, even when that meant ignoring hospital regulations and best practice.
Clinical freedom should be encouraged, and few medical decisions are so clear-cut that debate and disagreement should give way to blind adherence. But the message from Lewis and Tully is that the hospital environment of hierarchy, etiquette and conformity is causing discomfort to prescribers. Good teamwork is thought to lead to better care, although this study highlights how team dynamics may not always be in the best interests of patients.
Some readers might shun this work with its qualitative methodology, but it is a study with a real feel, the best kind of qualitative research. Clinicians at all levels need to improve the environment for their junior colleagues. ‘I'm very approachable,’ says one registrar, ‘but I think people may find it more difficult to come to me and say "oh you’ve done that wrong".’ Those three sins of hierarchy, etiquette and conformity might be uncomfortable for prescribers but they are potentially deadly for patients.
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