Primary Intentions

Throughout my career, I keep hearing colleagues say that we want safe doctors. But they can’t tell me what a safe clinician is—there’s no robust definition. It’s a buzzword I see repeatedly used.

What I also see is the mentality of: “As long as they are ‘safe’, that is okay, and they can go on their merry way.” It becomes accepted that this person’s practice is fine even if they over-order every test, refer everyone, never take clinical risks, depend heavily on specialists, and practise algorithm-only medicine. Okay—they’re safe. But are they a critically thinking doctor? Is this the standard?

Because there is no shared definition, clinicians assume many things about what a safe clinician is. The concept becomes warped, and the following features emerge:

• The “what-if” game gets played constantly—and then cognitive biases take hold. Catastrophising, blame avoidance, and regret avoidance emerge and drive the behaviours that follow.
• Over-investigating—defensive, low-value testing that generates false positives or incidentalomas, creating more problems than it solves.
• Referral bots—calling this person, then another person, then another person, and before you know it every surgical team has been involved.
• Lack of clinical risk-taking—fear of litigation if a rare adverse event occurs as a result of a treatment decision is something I see often.
• Specialist worship—“they said X, therefore X”, and never committing to their own decision-making.
• The desire to not miss anything—and before you know it every test, scan, and specialist is involved.
• Fear of litigation—which underpins a lot of the above features and I will reserve for another time

The perception of a “safe” clinician can become so distorted that it turns into a euphemism for someone who is conservative, defensive, and engaged in low-value practice.

I fell into these behaviours earlier in my career and sometimes still do. I haven’t had colleagues talk about it, nor have the specialists I work with really engaged with these issues directly. It has mostly been through indirect feedback. For instance, a consultant might say, “This is not likely, so we’re not going to do that. The evidence points towards this as the diagnosis. Therefore… such and such.” Years later, I wonder what we could introduce earlier so that, as a profession, we not only become cognisant of this, but are also given tools to diminish its grip on our practice.

In this wasteland, the A-type personality is very likely to be left behind and become deep-fried in the pursuit of being safe.

If we were to define what a safe clinician is, it would include the following features:

• Utilises clinical reasoning to explain the decisions they are making
  • For instance, I am not performing blood tests or a chest X-ray in a 40-year-old woman with community-acquired pneumonia who has no vital sign abnormalities and a clear history and examination pointing to it. The diagnosis has been made clinically; antibiotics with appropriate safety-netting is sufficient care.
• Recognises risk and responds appropriately
  • Using the previous case: it is now a 67-year-old man with haemoptysis and a smoking history. No other factors have changed. The clinical diagnosis still points towards community-acquired pneumonia; however, recognising the risk of complications and malignancy leads the clinician to order a chest X-ray.
  • In contrast, someone who doesn’t do this might send a vitally stable 70-year-old with a clinical diagnosis of CAP to the emergency department for a chest X-ray simply because it is the weekend—despite the person being fit and independent and having a strong safety net (e.g., their son lives with them).
• Awareness of scope limitations
  • This is tricky—exploring the idea of conscious incompetence vs unconscious incompetence.
• A strong follow-up system
  • This includes the safety-net we set for patients in general practice.
  • It also includes the education we provide on when to return for review—which requires placing appropriate trust in patients to do so.
  • And it includes systems for results follow-up, recalls, and handovers.
• Communication
• Professionalism—don’t be a dick
• Cognitive bias awareness
  • A disappointingly under-appreciated aspect of being a safe clinician—and no one seems to really talk about it.
• Responsiveness to feedback
  • We are all trying to grow as doctors—we want to be better.
  • Being defensive does not help.
  • Arguing, “This is just how they practise,” is also a terrible take.

We should not be arguing that doctors should be safe; we should be pursuing competence in our profession, combined with being calibrated to operate in a world of risk.

We want competent and calibrated clinicians:

• Competent, based on sound knowledge and appropriate assessment
• Calibrated, where the response matches the risk

If we change our wording about what we want from ourselves and our colleagues, with clearly defined parameters, we can avoid the pitfalls created by labelling ourselves as “safe”. What I want are clinicians who are competent, risk-calibrated, and make judicious decisions.