In the results of this study we describe the way in which junior and senior doctors' professional approaches vary in each category. Quotations to illustrate these variations are presented in the text.
Using theoretical knowledge
Theoretical knowledge (about how to handle a clinical situation/case, based on procedural and scientific knowledge, means-ends rationality) was not prominent or commonly described by SDs. Rather, they expressed theoretical knowledge as a component that is matched against their own experience of different cases and clinical courses. The utterance below illustrates how SDs express theoretical knowledge when diagnosing a patient with suspected instable angina.
There was this worried, Swedish-speaking woman with exactly the same problem [as a man with diffuse symptoms described by the doctor earlier,] /.../...and say that there is no indication of chest pain in the history, for instance, heart enzymes were negative, no on-line recording, and it was quite similar to the other case I talked about. (SD)
In contrast, theoretical knowledge was often used by JDs and seemed to contribute in a substantial way to forming valid clinical judgements. The quotation below illustrates how a JD used theoretical knowledge to reach a conclusion step by step.
Well, that she gets a pain in her chest when she exerts herself, and that nitro that she's been given or Suscard (nitroglycerine) helps, and also, in connection with chest pains, she's fainted several times and that this is very alarming, of course. (JD)
Using previous experience of cases and courses of events
SDs frequently referred to their experience of previous cases and clinical courses in their clinical judgements. When they said that something was typical, divergent or common, it was in the light of their considerable experience of cases and events. SDs describe how they use prior experience in judgements concerning risks, prognosis, management, decisions concerning difficult and complex situations, and when they interpret examination findings. The quotations below describe how previous experience is used, in recognizing a particular disease/symptom, and in supporting a patient and his/her relatives during a difficult terminal stage.
..... the voice, I said. No, no one had thought anything about that. Strange, I said, so we went up to him and said hello to him, and it was a completely classic example, that this man had a myxoedema. You could tell by his voice, and I hadn't seen the patient, and the pieces all fell into place. (SD)
....I was able to go back and say: I've seen this before, and I know that this is what often happens, you see. Sometimes it goes like this, but sometimes it goes like that...(SD)
JDs had more limited experience, which they did not yet trust fully in clinical judgements. They used their experience of previous cases and events to reflect on their clinical judgements.
Well, it wasn't a Cushing like you see in the books/.../No, you know they are ... the typical ones have thin arms and abdominal fat, and a thick neck and round faces, but she was a bit like that, but/.../I noticed it before but I thought it was so little. (JD)
The type of course that JDs discussed was short, and the statement below illustrates the reasoning concerning the outcome of cardiac arrest situations experienced at the emergency unit.
I mean if you've seen any cardiac arrests in Emergency you realise first of all that not many people make it from Emergency up to the hospital. (JD)
Adopting an ethical and moral approach
The ethical and moral considerations of SDs were prominent and conclusive, and they referred to their clinical experience in motivating judgements regarding: the approach to the patient, prognostic outcome, physiological and physical consequences as regards the patient's wellbeing, and the risk of "over-treating" and harming patients. The quotations below describe ethical and moral considerations, concerning choice of treatment in relation to effect and the patient's quality of life.
... you shouldn't start using a drug that destroys their life or destroys their quality of life. (SD)
..it's a lot about making sure that such patients are not left for a long time in the respirator, because it's very painful, you know. We place them in the respirator when we judge that we, it's likely that we can get them out after short-term treatment, you see. Otherwise we don't do it because it's so extremely painful. (SD)
JDs' ethical and moral standpoints were mostly seen in their communication with patients and in relation to limited healthcare resources, i.e. using them in the most cost-effective way. Their judgements were mostly founded on their own personal assumption (not experienced-based, as with SDs) of how you should behave in a general ethical and moral manner.
I feel that he isn't capable of really taking advantage of the benefit an operation should give, and you can't simply operate on everybody who has angina, and then we have to choose the ones that have the best chances of benefiting from the result in the best way. (JD)
Well, as far as I'm concerned, I don't think it matters very much, but for the relatives I think it can be very helpful [to see their dead relative before the respirator is disconnected]. (JD)
Meeting and communicating with the patient
SDs drew attention to the unique elements in each meeting with patients and situations. They also emphasized the importance of communication in clinical work and underlined the patients' vulnerability and needs. SDs also described how they handled their own needs and controlled their behaviour when communicating with the patient.
I don't show that I'm irritated, angry, pressed for time, or if the patient is insolent. I try to take it in good part, because I can. (SD)
Their description reflected two-way communication, as exemplified in the statements below.
... this woman, she was a gifted woman who understood her situation well and wanted, it was obvious, she wanted to have information about how she should cope [with a difficult course of illness] and her husband wanted that too. (SD)
Well, it's a way [talking with the patient] of getting the patients to take their medicines, to make them understand, of course they must be informed about why they have their medicines and why they need to take them, otherwise they might skip them. (SD)
JDs based their approach to patients on general clinical procedures and focused their attention on how to act, and on providing information. The statements below show that one- way communication was typical of the doctor-patient relationship described here.
..it's always important to take a history, and I did, of course, here, and I was going to take that type of history, I was going to, I did take it. (JD)
It's very important to go in and say hello to the patient ./.../It's the first contact, so that the patient knows who he or she is talking to. So then you can say, like, I'm a specialist or a house officer, because they know I'm not a consultant. So they can't demand answers to all the questions, and sometimes I can't, so to speak. (JD)
Focusing on available information
SDs' statements showed that they searched for and used available information in, for example, medical records. This approach was considered to facilitate an early diagnostic hypothesis and economize with healthcare resources.
You can kind of skim through quickly and still see things without really searching for them, but if you practise it, it works reasonably well in any case, and then I found an answer that wasn't recorded in the discharge notes, that he had a digitalis [dose] of around 4, which is definitely toxic, isn't it, and problems with digitalis when [due to] hypersensitivity, and then it's.... then you haven't made use of the information either, have you? (SD)
JDs described situations where they had to make judgements based on limited information, due to insufficient/or lack of time, medical records, medical examination results and/or experience/knowledge. This implies that judgements had to be made according to the information and time available.
There are twenty-eight patients lying and waiting for you and the corridors are full, and then you make a decision, as I mentioned a bit before, and the whole job consists of decisions, of course. Is this a clot, no it isn't a clot. Well, what is it then? And then you decide something, and then you've made that decision. (JD)
Relying on one's own ability
SDs were aware of their role as experts in a field. They knew how to act and knew what to do in complicated cases. They also knew they were the professionals who had to make the final judgement. Personal qualities such as honesty, integrity and self-knowledge were suggested as being important characteristics, for facilitating high-quality judgements and in relations with patients.
Knowledge and it's, I mean, the strength a specialist has in an area, it's that you can a bit more safely say that now it's not possible to do any more. There's nothing more that can be done and you know that then, and feel and say that this is a correct judgement, and the patients feel that too, you see. That's the way it is, you see. Perhaps it's an important component in the whole situation. (SD)
Being honest with yourself and with the patients makes it easier to handle these difficult things, both lack of knowledge and when we can't do anything more. (SD)
JDs also had to trust their ability to act in the right way, and had to be able to explain their reasons for action, though their confidence in their own ability sometimes seemed limited. The statements indicate that this seemed to be due to the fact that their role as a doctor was not fully developed or that they lacked clinical experience.
So I thought, from my amateurish point of view, from that perspective, I thought it would be best to operate on him, but ... I can feel that this is not something for me to decide. (JD)
They could also experience limitations in ability, for reasons connected with age and sex.
... he's been in and tried to talk to the patient too, because it can be a good thing sometimes. In other words, a man and a bit older, then they might understand, because I mean I look more or less like the assistant nurses or registered nurses, you see. (JD)
Getting support and guidance from others
All the same, SDs knew they were experts, and they turned to other experts to get confirmation on clinical judgements in order to create greater trust in patients. They also turned to other personnel with considerable clinical experience, for opinions about judgements.
...or a patient comes and says oh, I had such a pain in my chest all night, and then you see a strange ECG and then I sometimes run to a colleague with a bit more experience and discuss an ECG, and then I tell the patient that I've talked to a heart specialist here, and then they look rather pleased. (SD)
They're confined to bed for a long time after transplantations and sometimes it affects the problem of managing the operation itself, so that the physiotherapist also plays a certain part in assessing muscle function after the transplantation. Often they're the ones who've decided or think that this (situation) is too bad. (SD)
JDs frequently asked for support and opinions from others when making clinical judgements. There were four main reasons for doing this: to consult colleagues within their own speciality; to hand over responsibility; to obtain specialist knowledge other than their own; and to obtain another doctor's opinion on a clinical judgement that they had made. JDs also compared their own clinical judgements with those reached by other more experienced doctors. They were greatly influenced by judgements made by more experienced doctors and they described how they followed their advice despite having doubts.
...interpretations and tests are also very important, and it can also be tricky, and then you ring and wait for the doctor. They don't have to be much older either, so long as they have worked longer than I have. (JD)
I had relied completely on what psych [the psychiatric specialist] had advised about medication. (JD)
Being directed by the organization
JDs expressed that they were directed by the healthcare organization when making clinical judgements. There were restrictions due, for example, to shortage of staff, lack of time and shortage of hospital beds.
I usually go and check in the old records if I don't have access to the current one, and I hadn't got it just then. It was about six in the morning and they couldn't get it out then. (JD)
Organizational directions were also expressed as opportunities in the healthcare organization; for example, as knowledge about specialist care (experts and specialist wards) and procedures in managing patient care (investigation procedures). In the statement below, the JD expressed such directions in taking into consideration when the patient was to have her X-ray, and decided that the patient would have to remain in hospital.
There's probably a one- to two-week wait for this coronary artery X-ray, so she has to keep a place here. (JD)
In this category there were no statements from SDs. This could be related to the fact that senior and junior doctors have different working conditions, with regard to both hours and duties. Another explanation could be that these situations were very familiar to senior doctors and were therefore not mentioned.