Sunday, 5 February 2012

What is common sense?


At a conference I went to last week, I was struck by a recurring comment from different speakers. One of the themes of the conference was how to prevent unnecessary admissions to hospitals, and most of the speakers advocated the use of some decision-making tool (the dreaded protocol) in order to ensure that junior doctors had a better chance of making the right decisions consistently.

However, each of the speakers that promoted the use of protocols also criticised junior doctors for failing to use their common sense on occasions, and rigidly (incorrectly, they asserted) sticking to the protocol.

This struck me as unfair for a couple of reasons. Firstly, the practice of asking junior doctors to refer to protocols to guide their decision-making is borne out of the recognition that absence of protocols leads to inconsistent and sub-optimal decision-making. One of the challenges of learning to be a doctor is accessing the right knowledge and process in the heat of the moment, and protocols are an invaluable way of calming the waters, giving the time to focus, think and do what is best for the patient.

Junior doctors recognise that there is always the possibility that they may make a mistake (they are usually terrified by the prospect), and therefore are comforted by having the treatment pathways laid out before them. This means that they can focus on assessing the patient, instituting the correct treatment, and not spend too much time trying to figure out what the right treatment is.

The main pitfall of protocol-based medicine is that is relies on the assessing doctor having a high degree of certainty that the diagnosis is right, but such confidence is often hard to come by, either in the middle of a busy shift, in the middle of the night, or in a new specialty. Most protocols recognise a degree of diagnostic uncertainty, but perhaps not enough.

This is the moment that junior doctors need support, and we all need to ask whether we either offer or receive the kind of support we need from other people we work with to make the right decisions; a piece of paper outlining what you need to do in a given situation is really helpful, but it does not replace the comfort of the guiding hand of a colleague.

The second source of unfairness comes from the suggestion that the mistakes that junior doctors were making were a failure to apply common sense. But who’s common sense are they applying? Was it the common sense of someone dealing with the real stress of being a new doctor, in an unfamiliar specialty, trying to remember a hundred different things, or was it the common sense of an expert, who has worked in the field for a couple of decades? Is it fair for me to make a distinction between the two?

One might argue that common sense is by definition universal, and you would be right. My point is that the decisions on which these consultants poured scorn sounded silly in the context of consultants who have had the chance to learn and adapt to the stresses and requirements that the junior doctors they are criticising are still trying to adapt to. If one remembers that bad decisions are made by young professionals not just trying their hardest, but also trying to deal with lots of different types of challenges, then mistakes become forgiveable and indeed predictable. The responsibility, therefore,  becomes ours to ensure that they receive the support that they really need.

I often remind myself how hard it has been becoming a doctor, and how much courage it has taken to pick myself up from my failures. I need to remind myself that the need for courage has not disappeared, and I need to be prepared to fail again.

People I meet often seem to forget that becoming a doctor involves some graft, and they weren’t always as accomplished as they are now. Perhaps we should remind each other a bit more.

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