The Art of Prioritisation in Medicine: A Junior Doctor’s Odyssey

By Dr Joel Conway

I had fallen prostrate into bed after a day of doubt, anxiety, and toil. “Did I really win the ‘SJT lottery’ when I was allocated a house officer position at this lively East London district general?” I thought to myself. [The SJT was the exam, based on soft skills, that, for the last decade, had dictated where British medical graduates start their careers.] One could argue that the workload of a junior doctor is often overestimated. This perspective may hold some truth; nevertheless, I could not deny the fleeting moments of self-loathing and burden I felt at that time, all stemming from my career choice. This feeling is fleeting because I swiftly recover when reminded of the immense satisfaction and warmth that accompanies a fruitful family discussion, a successful insertion of a cannula, or that special moment when I check off the final item on my daily to-do list. Yet, it is also accompanied by self-loathing, as I am haunted by the guilt of prioritising my drive to emulate my ideal of a conscientious physician over the vague allure of other career paths I may occasionally regret not pursuing on a given day. If someone reading this shares these pensive moments, then I hope they have at least started a journey of reconciliation similar to that which is described in this essay. Learning to effectively prioritise served as sure-footing for correctly utilising channels of escalation, impartially dividing labour and effectively allocating time. In turn, I have begun to value the role of a junior doctor, and my individual role, in the multidisciplinary team and have maintained both my personal health and professional development throughout my early career.

Throughout medical school, I had a sense of having time at my disposal. However, in my first year as a doctor, it felt like time managed itself. The common warning was that working beyond five o’clock would be the norm during your debut month as a doctor, but during my initial stint in general surgery, staying late was a rare occurrence. At the time, I credited this to the dedication and hard work of my colleagues. In hindsight, I now understand that the relatively lighter workload was likely due to the regular junior reviews. In my view, the complexity and attention to detail in the assessment and planning of a newly qualified doctor differs from that of an experienced one, potentially resulting in longer job lists. My approach to managing a straightforward case of healthcare-acquired pneumonia, for instance, typically involved three key steps. First, administer antibiotics, a fundamental practice ingrained during medical school. Second, write up intravenous fluids to prevent the night team receiving any calls regarding a hypotensive patient unable to tolerate oral fluids. Lastly, consult a senior colleague. I was confident that any potential medicolegal repercussions would be evaded if you document the line ‘discussed with senior’. However, upon entering my first medical rotation, I discovered that a respiratory physician might offer a more comprehensive approach, encompassing blood and sputum cultures, atypical screens, a detailed radiograph review rather than just relying on the radiographers’ report, and other valuable insights.

When a dedicated physician takes a patient’s history, conducts a thorough examination, and truly delves into their problems, it’s nothing short of inspiring. It’s a moment where things change, and the patient feels genuinely cared for. However, this meticulous approach did have an unintended consequence – a remarkably long plan at the end of that day’s page. (During my early hospital roles, I had no choice but to rely on paper notes, which offered an alternative to the convenient and legible electronic documentation I’m now accustomed to). Striving to meet the high standards set by well-meaning consultants meant juggling extensive collateral histories, detailed referrals, and frequent communications with the laboratory to follow-up samples sent “x” days ago. I felt compelled to complete these tasks promptly, I knew they did not need to be done the same day but when left undone it felt like I was not working at my full potential. I eventually learned that this wasn’t the case.

So, during my early days in my first medical job, I found myself staying late, and I wasn’t alone in this. The other house officer on the ward stayed even later. However, it wasn’t because she was less effective; in fact, she was more diligent than I was. She, like many doctors^2,3, was a perfectionist. Believing that staying late was a direct consequence of sluggish task completion, I redirected my focus towards these tasks. As a result, my patient reviews became more efficient, as did my documentation. I was working harder, but not necessarily smarter. Focusing on clerical duties began to consume my thinking, and I deeply regret not fully using that time for learning and practicing medicine.

I had supportive seniors and a wide range of presentations flowing through the hospital, but, in my mind, the urgency of my clinical responsibilities were disproportionate. This skewed perception hindered my ability to provide genuine patient care and impeded my personal learning and mental health. As I have become more experienced, my understanding of prioritisation has improved. In my initial job, I lacked an understanding of the significance of each scan or blood test. I sought reassurance and guidance for every chronic issue that my mind wrongly perceived as acute. The imposter syndrome I have been managing since medical school had led me down into the valley of despair of the Dunning-Kruger curve, questioning my every decision. Yet, as I accrued experience, I became more attuned to my limitations and better equipped to judge the importance of various tasks. This self-awareness is pivotal for effective prioritisation.

Equally crucial is recognising when to seek help. I learned that it’s not a sign of weakness but a display of wisdom. As I gained clinical awareness, I developed an intuition for identifying cases or situations that exceeded my expertise, necessitating the involvement of a more seasoned colleague or specialist. Fortunately, most specialists are eager to discuss their area of expertise and provide guidance. In the rare instances where requests for assistance were met with disdain, it could be a bruising experience for the ego and a source of stress. However, I found that clear communication and effectively identifying and conveying critical aspects of a case helped reduce the frequency of such challenging encounters. I’m proud to say that I am no longer hesitant to reach out to the Microbiology team for advice when needed.

During my only medical school interview, I was asked, “How do you cope with stress?” I had a pre-prepared response in my mind: “Firstly, make a to-do list, then prioritise tasks, and finally, work through them in order of importance.” I believed this answer, inspired by Atul Gawande’s book on the power of checklists⁴, was what the interviewers were expecting. However, the truth was somewhat different. While I had experimented with this technique, my natural inclination was to procrastinate on important matters until the last minute. In reality, I had experienced relentless anxiety during A-levels, medical school applications, and in my personal life. The interviewers either accepted my response as sincere or acknowledged the mistruth and offered me a place anyway.

It wasn’t until I became a doctor that I truly understood the importance of prioritisation in managing stress, as I had mentioned during the interview. I am still surprised at how often following my past self’s advice becomes the key to resolving my current issues. How many times have I offered recommendations on sleep hygiene, dietary modification, or… alcohol cessation, fully aware that I wouldn’t follow it myself? No wonder one in four people in the Britain feel that, all things considered, UK doctors cannot be trusted.³

Saying ‘trust me’ is not enough to earn trust. Rapport is essential, or at least body language and nomenclature that conveys trustworthiness. On my first day as a doctor, I was the sole junior covering the surgical wards and was called to see a patient who had become confused. My internal monologue started whizzing through the emergency assessment I had practiced on a plastic dummy a day prior. “A fine, B fine, C oh that systolic is a little low, D… what is in D again?”. The nurse handed me a blood glucose monitor, probably following along with my silent assessment. “Thank you, this reads 1.7. I think we should set up a bag of 20%”. That might seem like a reasonable plan. Except that 20% does not come in bags but a little glass bottle. I also prefaced my instruction with ‘I think’. Finally, the term ‘we’ is also ambiguous, I should have looked at the yellow badge of one of the supportive, and faintly concerned, faces all looking to me for a plan and asked a specific individual to do so. This started a dispute between some of the nurses. The first issue was that a senior nurse stated the guidelines said 10% dextrose for a hypo, another protested and said glucagon was the first step. I had a similar scenario fresh in my head from simulation, and I was sure of what I wanted them to do. The group conversation lasted 5 minutes until an intensive care outreach nurse appeared, seemingly out of nowhere, with the 20% connected to a giving set. I share this because, it led me to reflect on how I communicate priority. I have described how I have learnt to infer urgency, thus far, but communication takes more than just a listener. Implying the priority of a task is just as challenging. There are a number of practical tools⁵ including closed loop communication, direct and time-dependent instructions and creating time for feedback or questions. But getting to know my colleagues has nurtured an environment of trust and free communication, which, in turn, has resulted in effective prioritisation within the team. I have found that clarity and openness in communication are more important than any rigid tools that can be forgotten or dismissed as an excessive convention.

In the intricate world of medicine, prioritisation is the linchpin for both individual practitioners and the broader healthcare system. This understanding has become abundantly clear after my first year of experience. Transitioning from the structured environment of medical school to the bustling realm of a junior doctor feels akin to leaving an aquarium to navigate the open ocean. While medical school imparts knowledge, it is clinical practice that truly tests one’s decision-making abilities. Experience becomes invaluable as novice practitioners learn to weigh tasks and determine when to seek expert guidance. Prioritisation isn’t solely about managing a task list; it stands as a cornerstone of patient care.

Within the intricate choreography of a healthcare team, clear communication and trust serve as the regulatory framework, ensuring seamless cooperation. Striking a balance between the complexities of medical practice and personal growth represents a delicate equilibrium. In the future, I will prioritise my own well-being and development over service provision.

In conclusion, the art of prioritisation in medicine, as seen through the eyes of a junior doctor, is a nuanced symphony of communication, reflection, and time management, all of which are vital for personal and collective success.

References

1. Parkinson, N. Parkinson’s Law . The Economist. (1955).
2. Peters, M. & King, J. Perfectionism in doctors. BMJ (Clinical research ed.) vol. 344 Preprint at https://doi.org/10.1136/bmj.e1674 (2012).
3. Blendon, R. J., Benson, J. M. & Hero, J. O. Public Trust in Physicians — U.S. Medicine in International Perspective. New England Journal of Medicine 371, (2014).
4. Gawande Atul. Checklist manifesto, the (HB). (Penguin, 2010).
5. El-Shafy, I. A. et al. Closed-Loop Communication Improves Task Completion in Pediatric
   Trauma Resuscitation. J Surg Educ 75, (2018).