Doctors often have to make and act on important decisions based on a limited evidence base. How can we ensure that our newest colleagues feel secure in the face of uncertainty?
Medicine is a science of uncertainty and an art of probability, so the saying goes. This is precisely the topic of the study carried out by Ofstad et al. that appears in this edition of the Journal of the Norwegian Medical Association (1). Stage 1 specialty registrars (LIS1 doctors) at two Norwegian hospitals were interviewed at the end of their year of hospital training. The purpose was to explore how LIS1 doctors perceive and manage uncertainty in clinical practice. The main findings were that the doctors struggled with the inherent uncertainty of medicine and were particularly insecure at the start of their specialty training, and that a secure working environment was considered important.
Qualitative methods build on theories of interpretation (hermeneutics) and experiences of human beings (phenomenology), with a view to exploring the meanings of social phenomena as experienced by the actors themselves within their natural context (2). There will always be distortion when a spoken conversation is converted into written text. The purpose of transcription in this context is to capture the conversation in a form that best represents what the informant intended to convey. The quotes in the article illustrate the researchers' findings, but are not in themselves independent results, even if they present a picture of reality that is recognisable to many.
Uncertainty about one's own competence in the early stage of a career can create insecurity, and feeling insecure at work can also reinforce uncertainty
Ofstad et al. found that the LIS1 doctors used the terms 'certain/uncertain' and 'secure/insecure' interchangeably. Uncertainty and insecurity are complex phenomena that are difficult to separate from each other and which are also assumed to influence each other. Uncertainty about one's own competence in the early stage of a career can create insecurity, and feeling insecure at work can also reinforce uncertainty. Dealing with uncertainty is not only about obtaining the necessary information and relying on helpful colleagues – described in the article as a curative approach – it also involves developing appropriate coping strategies for living with this uncertainty – feeling secure about it.
'I get physically sick ... Sometimes I wonder if I've done something stupid, if I should be a doctor. Because feeling that uncertainty is so challenging.' This is a quote from one of the LIS1 doctors in the study, and many doctors, even the more experienced ones, can probably relate to this. This winter, orthopaedists at Akershus University Hospital raised the alarm: low staffing led to the doctors fearing both for the patients and their own health (3). The headline 'Doctors cry on duty and hope to catch a stomach bug to get out of working' aroused strong feelings within and beyond the medical community. This case is an example of how short-term cost-cutting measures, stringent operational requirements and organisational changes to reduce costs in the health service can come at the expense of time and the opportunity to provide good patient care.
Hospitals need to plan for more doctor-to-doctor time in order to enable proper supervision and guidance
Hospitals need to plan for more doctor-to-doctor time in order to enable proper supervision and guidance. Compared to poor follow-up and supervision of doctors in specialty training, good follow-up and supervision reduces medical errors, expedites professional progression, improves patient care standards and provides reassurance for doctors. A high standard of specialty training is a prerequisite for producing well-qualified specialists.
When the regulations on specialty training for doctors were introduced, the health service was not prepared for the major restructuring that this would entail. The last nationwide evaluation of specialty training for doctors was carried out in 2015. Stage 1 of specialty training has not been subject to a national evaluation since it replaced the old system in 2017, and the Norwegian Medical Association is therefore in the process of re-evaluating this across the regions.
Ofstad et al. conclude that the main aim of stage 1 of specialty training should be for doctors to experience a secure learning environment. A sense of security in clinical practice, a good working environment and a positive culture of openness are necessary prerequisites for a high standard of professional practice, both for LIS1 doctors and their colleagues. Investing in specialist training for doctors right from the start makes good economic sense. Secure doctors are a prerequisite for delivering good patient care.