Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review

Inclusion criteria

• Aspects of antimicrobial prescribing: all studies that focused on one or more aspects of antimicrobial prescribing (or when combined with other types of prescribing). A comprehensive definition of prescribing proved challenging to identify in the existing literature. Therefore, we viewed prescribing as the act of determining what medication a patient should have and the correct dosage and duration of treatment. We also acknowledged how prescribing requires a ‘mixture of knowledge, skills and judgement’ as there is ‘no simple relationship between knowledge and behaviour’. 43

• Study design: all study designs.

• Types of settings: all studies that were conducted in hospital or primary care settings.

• Types of participants: all studies that included doctors in training (any specialty and at any level).

• Types of intervention: interventions that focus on changing/developing antimicrobial prescribing behaviour or studies discussing how doctors in training engage with antimicrobial prescribing.

• Outcome measures: all prescribing-related outcome measures.

Exclusion criteria

• Studies focusing only on drug administration (no prescribing decision).

All citations were reviewed by Chrysanthi Papoutsi to ensure that they matched the exclusion and inclusion criteria. A 10% random subsample was reviewed independently by Geoff Wong to ensure consistency around the application of the inclusion criteria. One small inconsistency was identified as a result of different interpretations of junior doctor roles, but this was easily resolved through discussion.

Inclusion criteria

• Studies discussing the role of hierarchies, teamwork and decision-making, in relation to doctors in training.

• Study design: all study designs.

• Types of settings: all studies that were conducted in hospital or primary care settings.

• Types of participants: all studies that included doctors in training (any specialty and at any level).

Exclusion criteria

• No prespecified exclusion criteria.

All citations were reviewed by Chrysanthi Papoutsi to ensure that they matched the inclusion criteria. A 10% random subsample was reviewed independently by Geoff Wong to ensure consistency in how the inclusion criteria were applied. There were no differences between reviewers.

Realist analysis

Relevant extracts from papers included in the review

1. ‘I think it goes from the top down so everybody has to do the same thing. If the consultant or registrar doesn’t set a good example, the junior will certainly not follow it [the good example].’ (Specialist Trainee Doctor, Stroke)

Reproduced from Charani et al. , Understanding the determinants of antimicrobial prescribing within hospitals: the role of ‘prescribing etiquette’, Clinical Infectious Diseases, 2013, vol. 57, iss. 2, pp. 188–96,35 by permission of Oxford University Press

1. ‘Whatever attending [physician] you are with is the attending who you learn from, and if I see them continuously not prescribe antibiotics over and over again, then I feel comfortable not prescribing antibiotics. But if they always do it, then I feel the need to do it’. (Resident interview)

Reproduced with permission from Livorsi et al. 70

1. ‘I actually have been criticized by a staff because of not covering somebody [with antibiotics . . . ] I was suspicious for endocarditis but they were clinically stable and so I wanted to get multiple blood cultures and monitor . . . The next morning I was pretty severely reamed out for not covering the patient [with antibiotics], although the person did fine and did not have a bad clinical result.’ (Resident interview)

Reproduced with permission from Livorsi et al. 70

1. ‘Because if you make a mistake, it is going to be the primary concern of the patient, of course, and something bad is going to happen to them. And then you have your personal reputation to think about, too.’ (Resident interview)

Reproduced with permission from Livorsi et al. 70

1. The data [included in this paper] tell us, however, that junior doctors’ decisions and behaviours are also influenced by the prevailing culture of the organisation and the juniors’ perceptions of the hierarchy within which they work.

Reproduced with permission from Tallentire et al. ,72 © Blackwell Publishing Ltd 2011

1. When focusing on the role of the supervisors, both internal medicine and surgical residents emphasized their importance as role models because supervisors’ practice strongly determined the subsequent prescribing behaviour of residents.

Reproduced from Cortoos et al. , Opposing expectations and suboptimal use of a local antibiotic hospital guideline: a qualitative study. Journal of Antimicrobial Chemotherapy, 2008, vol. 62, iss. 1, pp. 189–95,62 by permission of Oxford University Press

1. The most significant influence on prescribing practices was the opinion of more senior colleagues in the team to which the NCHD [Non-Consultant Hospital Doctor] was assigned. This was especially important in the earlier years of one’s medical career when doctors (particularly pre-registration house officers) have limited autonomy. [. . .] Instructions from seniors 1. ‘I did what I was told, like all interns do’ (Male Specialist Registrar, Anaesthesia) 2. ‘It’s a good system because he (Senior colleague) probably knows better than you; he may have a good reason’ (Male Registrar, Ear, Nose and Throat)

Reproduced from De Souza et al. , A qualitative study of factors influencing antimicrobial prescribing by non-consultant hospital doctors. Journal of Antimicrobial Chemotherapy, 2006, vol. 58, iss. 4, pp. 840–3,63 by permission of Oxford University Press

1. ‘Some registrars described feeling undermined or criticised by their supervisors for their prescribing decisions. [. . .] ‘It’s a big power differential . . . You’re still at the mercy of the training provider coming and doing visits, and your supervisor giving input on if you do what you’re told or not’. (Registrar)

Republished with permission of the Royal College of General Practitioners, from Antibiotic prescribing for the future: exploring the attitudes of trainees in general practice, Dallas et al. , vol. 64, edn 626, 2014;73 permission conveyed through Copyright Clearance Center, Inc.

1. For some registrars, there are concerns that they need to ‘do what they’re told’ or fit in to a particular practice culture to prevent conflict and ensure career progression [. . .]

Republished with permission of the Royal College of General Practitioners, from Antibiotic prescribing for the future: exploring the attitudes of trainees in general practice, Dallas et al. , vol. 64, edn 626, 2014;73 permission conveyed through Copyright Clearance Center, Inc.

1. ‘The origin of my practice came from supervisors during residency training, but the supervisors practised differently with respect to indication, dose, and number of doses. Thus, I chose to imitate the credible supervisors with good results of postoperative infection and my personal inclination.’ (Resident)

Data from Liabsuetrakul et al. 74

Realist analysis

Relevant extracts from papers included in the review

1. ‘When I was an SHO [Senior House Officer], you move around every six months and what you would have used, or what the consultant liked in one hospital, wouldn’t necessarily go in another hospital at all, you know? So to a certain extent you had to fit in a little bit with individual consultant preferences.’ (Female Specialist Registrar, Haematology/Medical Oncology)

Reproduced from De Souza et al. , A qualitative study of factors influencing antimicrobial prescribing by non-consultant hospital doctors. Journal of Antimicrobial Chemotherapy, 2006, vol. 58, iss. 4, pp. 840–3,63 by permission of Oxford University Press

1. ‘[talking about having to sign orders one disagrees with] not like anybody was forcing my hand [but when you are] lower on a team [. . .] I guess this is what I order.’ [Consultant discussing experiences as a trainee]

Data from Hilliard et al. 77

1. Today interns, residents, and registrars work with many health professionals and seniors on a day to day basis and are required to understand and implement instructions from doctors above them. Registrars work for five or more consultants. They are expected to follow the usually unwritten rules of each of their ‘bosses’ and to take instructions. This results in inadequate communication, fragmented supervision, inadequate instructions, and more frequent suboptimal patient outcomes.

Reproduced from Hierarchies: the Berlin Wall of patient safety, Walton et al. , vol. 15, pp. 229–30, 200678 with permission from BMJ Publishing Group Ltd

1. ‘You can tell like some consultants are just not interested in what [patients are] on whereas some consultants will ask if they’re on antibiotics. So it varies a lot between consultants, I think if they all start feeding it down it will work.’ (Pharmacist, General Medicine)

Reproduced from Charani et al. , Understanding the determinants of antimicrobial prescribing within hospitals: the role of ‘prescribing etiquette’. Clinical Infectious Diseases, 2013, vol. 57, iss. 2, pp. 188–9635 by permission of Oxford University Press

1. In addition to learning about prescribing from protocols and from others, doctors were also required to learn about the preferences of particular consultants, even if these did not fit with the protocols they had just learned. One of our participants told us that, after drawing on her knowledge of therapeutics, she had taken a complex prescribing decision with which she was happy. However, she reported: ‘Yeah, whereas if it had been the other consultant I would probably have started antibiotics . . . Because he is for antibiotics so it just depends on who the consultant is, you have to know who you are working for. [Foundation Year 1 Doctor]

Reproduced with permission from Kilminster et al. 79 © Blackwell Publishing Ltd 2011

1. This participant went on to discuss how workplace culture had influenced him to prescribe suboptimally in certain circumstances. Although he was aware of how it should be done, the social environment made suboptimal prescribing acceptable: ‘I’ll still prescribe Tazocin because someone will just say Tazocin and all my colleagues just write Tazocin, and it’s just Tazocin . . . Everyone else does it so you do it . . . You actually have that written as Tazocin on the antimicrobial [guidelines] . . . maybe that’s why I’ve been influenced . . .’ (First-year junior doctor)

Reproduced from McLellan et al. , Pharmacist-led feedback workshops increase appropriate prescribing of antimicrobials. Journal of Antimicrobial Chemotherapy, 2016, vol. 71, iss. 5, pp. 1415–2580 by permission of Oxford University Press

Realist analysis

Relevant extracts from papers included in the review

1. While there was some role variation depending on the particular environment and supervisors, interns generally saw their primary role as providing clinical administration to the team, under supervision. The intern role was low status: ‘at the bottom of the food chain’, ‘a dogsbody’, ‘bottom of the bottom’.

Reproduced from Advances in Health Sciences Education, Participation and progression: new medical graduates entering professional practice, vol. 16, 2011, pp. 627–42, Bearman et al. ,81 © Springer Science + Business Media B.V. 2011. With permission of Springer

1. In many cases, team members may feel less responsible for their own actions and will view themselves as just an ‘agent’ of their leader.

Reproduced with permission from Friedman et al. 82 © 2015 The Association of Anaesthetists of Great Britain and Ireland

1. Residents described themselves as being in the role of a bystander. An example from the simulation scenario was a resident who considered that he hadn’t actually ‘given blood’ to the patient [when this was inappropriate to do]. Despite acknowledging that he spiked the bag of blood and hung it on the intravenous line, in his view, he was just doing what he was told and someone else made the decision.

Reproduced from Canadian Journal of Anaesthesia, Residents’ reluctance to challenge negative hierarchy in the operating room: a qualitative study, vol. 62, 2015, pp. 576–86, Bould et al. ,83 © Canadian Anesthesiologists’ Society. With permission of Springer

1. One resident commented that the most important thing for him was that, if the regulatory bodies in Ontario investigated a case, he would never be found ultimately responsible for the case and would escape legal repercussions as he was following the directions of his attending. In his view, any real responsibility for a patient began once training was completed.

Reproduced from Canadian Journal of Anaesthesia, Residents’ reluctance to challenge negative hierarchy in the operating room: a qualitative study, vol. 62, 2015, pp. 576–86, Bould et al. ,83 © Canadian Anesthesiologists’ Society. With permission of Springer

1. Trainees describe how leadership equates to clinical responsibility. The person who has ultimate clinical responsibility within a given situation was perceived to be the leader.

Reproduced with permission from Gordon et al. 84 © 2015 John Wiley & Sons Ltd.

1. Although they considered themselves to be responsible solely for ensuring that a patient survived until senior help arrived, they also felt that they were abdicating responsibility if they did not attempt to assess, investigate, diagnose and treat a patient before calling for help.

Reproduced with permission from Tallentire et al. 72 © Blackwell Publishing Ltd 2011

1. In situations in which a resident physician was covering unfamiliar patients overnight, prescribing antibiotics was preferred when a patient’s clinical status declined; the expectation was that the primary team would de-escalate antibiotics at a later time if a bacterial infection was not present.

Reproduced with permission from Livorsi et al. 70

Realist analysis

Relevant extracts from papers included in the review

1. Antibiotic overuse is recognized but generally accepted. [This is one of the four themes identified by this paper on the culture of antibiotic prescribing.]

Reproduced with permission from Livorsi et al. 70

1. I think there is more pressure towards you are going to look bad if you missed something and did not treat it appropriately versus . . . giving people C[lostridium] difficile and diarrhea, [which] is a little more anonymous (resident interview). [. . .] While these participants’ sense of clinical competence was influenced by not missing an infection, they expressed less concern about their antibiotic prescribing decisions fostering C. difficile or an infection with ARB [antibiotic-resistant bacteria]. There may be several reasons why participants undervalued these adverse events. For example, these antibiotic-related adverse effects tend to be multifactorial; they may have a delayed manifestation; they may be difficult to attribute to a single physician’s decision, thereby providing a degree of anonymity for the prescribing physician.

Reproduced with permission from Livorsi et al. 70

1. Providers articulated that azithromycin prescriptions for upper respiratory prescription are perceived to be ‘like water’ and a ‘safe, cheap and effective’ choice and that they are thus given out ‘like candy’.

Reproduced with permission from May et al. 10

1. ‘. . . I always think that there is feeling in all of doctors that antibiotics won’t do anything [harmful] “one or two doses of ceftriaxone won’t kill anyone” [. . .]’ (Resident)

Data from Almatar et al. 66

Figure 5 consolidates CMOCs 1–5 described in the findings section so far and summarises the influence of hierarchical relationships on the prescribing decisions of doctors in training (presented as CMOCs). 10,35,56,60,62,63,66,69,70,72–76,78–98

FIGURE 5.

Partial programme theory (CMOCs 1–5).

Realist analysis

Relevant extracts from papers included in the review

1. ‘[. . .] what really is the law of the jungle is that whatever your senior says goes and that evidence and best practice (. . .) is never completely realised (. . .) that’s quite challenging.’ (Foundation Year 1 doctor)

Data from Vivekananda-Schmidt and Vernon100

1. A third theme in our interviews was the strong influence senior staff had on resident physicians’ antibiotic prescribing decisions. Studies from the United Kingdom, Ireland, and Belgium also identified senior opinion leaders as important determinants of antibiotic prescribing practices, superseding the influence of local policy.

Reproduced with permission from Livorsi et al. 70

1. Supervisor behaviour also impacts on this process. Some registrars see their supervisors prescribing contrary to guidelines, and find this a challenging dynamic to negotiate, mainly because of a differential of power and experience between registrar and supervisor. This tension between ‘experience and evidence’ and managing the complexities of relating within a hierarchical medical culture are a common experience for the doctor in training.

Republished with permission of the Royal College of General Practitioners, from Antibiotic prescribing for the future: exploring the attitudes of trainees in general practice, Dallas et al. , vol. 64, edn. 626, 2014,73 permission conveyed through Copyright Clearance Center, Inc.

1. [. . .] there is a dichotomy between the organizational expectation from juniors to follow official policy and the social and contextual norm of adhering to ‘prescribing etiquette’ set by one’s senior colleagues in their clinical groups, as the evidence in this study suggests.

Reproduced from Charani et al. , Understanding the determinants of antimicrobial prescribing within hospitals: the role of ‘prescribing etiquette’, Clinical Infectious Diseases, 2013, vol. 57, iss. 2, pp. 188–96,35 by permission of Oxford University Press

1. Hospital policies aimed at influencing the antibiotic prescribing behaviours of junior physicians had limited effectiveness because of the social norm of adhering to the ‘prescribing etiquette’ set by one’s seniors.

Data from Chow et al. 99

1. Particularly unexpected was the finding that local knowledge sources, especially colleagues’ opinions, were perceived as more effective in modifying prescribing behavior than national guidelines. In fact, many providers cited specific individuals and explained how their research or opinions directly influenced their antibiotic prescription practices.

Reproduced with permission from May et al. 10

1. Peer approval is one of the essential rules in the successful implementation of interventions [. . .]. Whereas nurses and pharmacists reported a reliance on policy to help promote compliance of junior doctors to evidence-based practice, doctors reported adhering to policy only if it was endorsed by peers from their own specialties and clinical groups.

Reproduced from Charani et al. , Understanding the determinants of antimicrobial prescribing within hospitals: the role of ‘prescribing etiquette’, Clinical Infectious Diseases, 2013, vol. 57, iss. 2, pp. 188–96,35 by permission of Oxford University Press

1. [. . .] locally developed guidelines for antimicrobial treatment are more useful than national guidelines. These perceptions suggest that guidelines promoted by ASPs [Antimicrobial Stewardship Programmes] are likely to meet with more success if they take into consideration local practices and patterns of resistance.

Data from Abbo et al. 101

1. Less experienced doctors may prescribe more appropriately according to guidelines, but develop behaviours and prescribing habits similar to their supervisors as training progresses.

Republished with permission of the Royal College of General Practitioners, from Antibiotic prescribing for the future: exploring the attitudes of trainees in general practice, Dallas et al. , vol. 64, edn 626, 2014;73 permission conveyed through Copyright Clearance Center, Inc.

1. This demonstrates how prescribing protocols and evidence-based medicine do not always determine doctors’ performance. Sometimes a particular consultant’s preferences carry more weight than formal regulation. We termed this ‘contingent performance’.

Reproduced with permission from Kilminster et al. 79 © Blackwell Publishing Ltd 2011

Realist analysis

Relevant extracts from papers included in the review

1. [. . .] determinants of why respondents trusted guidelines were: observing that the recommended practice worked, knowing that the developers had ‘looked into it, researched it, used evidence-based practice’ [. . .], observing more senior doctors using guidelines, and if the guideline was recent (i.e. in-date).

Reproduced from Barlow et al. 68 This is an open access article distributed under the terms of the Creative Commons CC BY license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited

1. ‘I think that the current policy is rational. The decision was made by a subgroup within my specialty, composed of people whose judgment I respect and chaired by people whose judgment I respect and I’m very happy to comply with the decisions that they make.’ (Senior Doctor, Renal Medicine)

Reproduced from Charani et al. , Understanding the determinants of antimicrobial prescribing within hospitals: the role of ‘prescribing etiquette’, Clinical Infectious Diseases, 2013, vol. 57, iss. 2, pp. 188–96,35 by permission of Oxford University Press

1. Senior doctors will overrule policy as they consider it subordinate to their knowledge and clinical experience that is gained over their years of practice – this pattern only gets reversed if the policies have the clear endorsement of senior peers within their own clinical groups. This is indicative of the role of hierarchy in influencing practice [. . .]

Reproduced from Charani et al. , Understanding the determinants of antimicrobial prescribing within hospitals: the role of ‘prescribing etiquette’, Clinical Infectious Diseases, 2013, vol. 57, iss. 2, pp. 188–96,35 by permission of Oxford University Press

1. The reported acceptance of noncompliance of senior staff with local policy is another element of prescribing etiquette. This noncompliance is justified first by recognition of the experience and expertise of senior staff and second, by a broader definition of ‘evidence base,’ which includes personal experience of individuals and the perception that policies are for the ‘average’ cases. Personal experience/expertise seems to win over evidence-based policies and guidelines.

Reproduced from Charani et al. , Understanding the determinants of antimicrobial prescribing within hospitals: the role of ‘prescribing etiquette’, Clinical Infectious Diseases, 2013, vol. 57, iss. 2, pp. 188–96,35 by permission of Oxford University Press

1. A clear distinction between the antibiotic opinion leaders and other members of staff, together with clear communication on the reasons to divert from the guideline, is of primary importance and could be an effective intervention.

Reproduced from Cortoos et al. , Opposing expectations and suboptimal use of a local antibiotic hospital guideline: a qualitative study. Journal of Antimicrobial Chemotherapy, 2008, vol. 62, iss. 1, pp. 189–95,62 by permission of Oxford University Press

1. Consequently education about guideline content was unlikely to change behaviour unless it was accompanied by regular feedback about doctors’ adherence to key guideline recommendations.

Data from Asseray et al. 102

Figure 6 consolidates the data presented in CMOCs 6–9 to summarise the influence of hierarchies on perceptions of guideline credibility and acceptability, and on the prescribing behaviours of doctors in training. 10,35,60,62,63,68,70,73,79,88,92,96,98–113

FIGURE 6.

Partial programme theory (CMOCs 6–9).

Realist analysis

Relevant extracts from papers included in the review

1. There was evidence that participants sometimes felt under pressure to prescribe antibiotics, when they did not feel that they were necessary, from both nursing and other ward staff, and from patients and their relatives.

Reproduced from De Souza et al. , A qualitative study of factors influencing antimicrobial prescribing by non-consultant hospital doctors, Journal of Antimicrobial Chemotherapy, 2006, vol. 58, iss. 4, pp. 840–3,63 by permission of Oxford University Press

1. ‘I do know one supervisor [in primary care] in particular will give his patients antibiotics even for something that sounds very viral, and therefore when I see his patients, I feel I’m expected to do that as well, because his patients have been seeing him for many years. So they expect it too, so I’m definitely more likely to give his patients antibiotics even when I don’t think it’s justified.’ (Registrar)

Republished with permission of the Royal College of General Practitioners, from Antibiotic prescribing for the future: exploring the attitudes of trainees in general practice, Dallas et al. , vol. 64, iss. 626, 2014;73 permission conveyed through Copyright Clearance Center, Inc.

1. GP [general practitioner] registrars have been sent emails to say that they should prescribe antibiotics, because that’s what patients expect, but that’s coming down from the older generations. (Registrar)

Republished with permission of the Royal College of General Practitioners, from Antibiotic prescribing for the future: exploring the attitudes of trainees in general practice, Dallas et al. , vol. 64, iss. 626, 2014;73 permission conveyed through Copyright Clearance Center, Inc.

1. ‘We’ve created an expectation in the population. They come asking for antibiotics, ‘cause the last three times they came, they were told they needed them. So they come time number four and say, “I’m here for my antibiotic.” And we think they’re crazy. When in reality, it’s like no, we trained them to come back and get an antibiotic.’ (Attending, male, 11 years)

Reproduced with permission from May et al. 10

1. ‘It’s almost like opiates. When the physician is just so beaten down that they don’t want to argue anymore with the patient. We all want to be that person who has that hard discussion and educates the patient, but sometimes it’s really hard to do that.’ (Attending, female)

Reproduced with permission from May et al. 10

1. [. . .] the pressure to ‘conform with perceived patient preferences’ rather than follow clinical guidelines [. . .]

Reproduced with permission from May et al. 10

1. [. . .] the patient has been given antibiotics in the past for similar presentations, thus the registrar questions their clinical acumen in the current situation.

Republished with permission of the Royal College of General Practitioners, from Antibiotic prescribing for the future: exploring the attitudes of trainees in general practice, Dallas et al. , vol. 64, iss. 626, 2014;73 permission conveyed through Copyright Clearance Center, Inc.

1. Physicians report that they prescribe unwarranted antibiotics because patients expect to be prescribed antibiotics, because patients bounce from physician to physician if antibiotics are not prescribed, and because it is quicker to write a prescription than to explain why the antibiotics are not indicated.

Data from Undeland et al. 114

1. Learning communication skills and confidence to build therapeutic relationships was perceived to improve also: ‘I think initially I was probably a lot less confident to say to patients no, and I think now it’s become a lot easier because I’m not afraid that they’re going to hate me and never come back’. (Registrar)

Republished with permission of the Royal College of General Practitioners, from Antibiotic prescribing for the future: exploring the attitudes of trainees in general practice, Dallas et al. , vol. 64, iss. 626, 2014;73 permission conveyed through Copyright Clearance Center, Inc.

Realist analysis

Relevant extracts from papers included in the review

1. ‘I had a similar case where a registrar prescribed a certain antibiotic and the pharmacist came up to me and said ‘these aren’t antibiotics that should be given’ and so I went and found the registrar and told him and he said ‘no keep them on’ but the pharmacist kept chasing me and I was like ‘no [laughs] do what the registrar says’. (Female Foundation Year 1 doctor)

Reproduced from Mattick et al. , A window into the lives of junior doctors: narrative interviews exploring antimicrobial prescribing experiences, Journal of Antimicrobial Chemotherapy, 2014, vol. 69, iss. 8, pp. 2274–8343 by permission of Oxford University Press

1. This set of unwritten rules, or ‘prescribing etiquette,’ dictates not only the prescribing behavior of doctors but also how other healthcare professionals (i.e., pharmacists and nurses) view and exert influence on the antimicrobial prescribing, administration, and monitoring processes.

Reproduced from Charani et al. , Understanding the determinants of antimicrobial prescribing within hospitals: the role of ‘prescribing etiquette’, Clinical Infectious Diseases, 2013, vol. 57, iss. 2, pp. 188–96,35 by permission of Oxford University Press

1. Senior doctors rely on their own professional judgment and the need to freely choose what they judge to be the most appropriate when prescribing antimicrobial prophylaxis or treatment [. . .]. This may involve making antimicrobial prescribing decisions that overrule infection specialist advice [. . .]

Reproduced from Charani et al. , Understanding the determinants of antimicrobial prescribing within hospitals: the role of ‘prescribing etiquette’, Clinical Infectious Diseases, 2013, vol. 57, iss. 2, pp. 188–96,35 by permission of Oxford University Press

1. And the number of times you felt like a piggy in the middle. You were being batted backwards and forwards. At the end of the day you’re just trying to do the best for the patient who is outside your expertise. (Female, early-stage GP trainee)

Reproduced from Leadership and followership in the healthcare workplace: exploring medical trainees’ experiences through narrative inquiry, Gordon et al. , vol. 5, e008898, 2015115 with permission from BMJ Publishing Group Ltd

1. Differences of opinion between senior colleagues on prescribing issues, usually consultants and other experts (e.g. microbiologists and pharmacists) disagreeing about an off-protocol drug, presented FY [Foundation Year] doctors with a dilemma: they often had to choose whose ‘side’ to take (12 mentions) and felt stuck in the middle (23 mentions [. . .]).

Reproduced from Mattick et al. , A window into the lives of junior doctors: narrative interviews exploring antimicrobial prescribing experiences, Journal of Antimicrobial Chemotherapy, 2014, vol. 69, iss. 8, pp. 2274–8343 by permission of Oxford University Press

Realist analysis

Relevant extracts from papers included in the review

1. ‘[. . .] I mean I think the junior doctors actually are sometimes quite glad to see us because they often want advice on what to do with . . . how to prescribe certain drugs because they often don’t know, especially the brand-new qualified doctors [. . .].’ (Pharmacist, Respiratory Medicine)

Reproduced from Charani et al. , Understanding the determinants of antimicrobial prescribing within hospitals: the role of ‘prescribing etiquette’, Clinical Infectious Diseases, 2013, vol. 57, iss. 2, pp. 188–96,35 by permission of Oxford University Press

1. Within the context of hierarchy and autonomous decision making, there may be a limited tacit influence on prescribing behaviors of doctors from nurses and pharmacists [. . .]. This influence may be transient, only limited to the behaviors of the more junior doctors, and only valid in situations where there is no conflict with the opinion or direction of senior medical staff, in which case the latter prevails: ‘Consultants. Those are the people who we listen to. It’s partly because we know the hierarchy, from the doctor’s side of things.’ Junior Doctor, Accident and Emergency.

Reproduced from Charani et al. , Understanding the determinants of antimicrobial prescribing within hospitals: the role of ‘prescribing etiquette’, Clinical Infectious Diseases, 2013, vol. 57, iss. 2, pp. 188–96,35 by permission of Oxford University Press

1. [. . .] pharmacists were listed in the survey and acknowledged by the JMOs [Junior Medical Officers] as an important information source.

Data from Welch et al. 91

1. ‘. . . although everyone was kind of looking at me . . . I noticed that one of the nurses was managing to get through to the patient and kind of getting him to listen . . . and I thought, I think ‘this is when I should be quiet and let this nurse deal with it’ and I just did what the nurse said . . .’ (Female, foundation trainee)

Reproduced from Leadership and followership in the healthcare workplace: exploring medical trainees’ experiences through narrative inquiry, Gordon et al. , vol. 5, e008898, 2015115 with permission from BMJ Publishing Group Ltd

1. There exists a social network within which antimicrobial prescribing decisions are made, and healthcare professionals report awareness of the need to work within this network in their specialties. [. . .] The rule of ‘noninterference with the clinical decisions of others,’ despite the existence of local policies guiding antimicrobial prescribing, is an example of the influence of this social network on behaviors.

Reproduced from Charani et al. , Understanding the determinants of antimicrobial prescribing within hospitals: the role of ‘prescribing etiquette’, Clinical Infectious Diseases, 2013, vol. 57, iss. 2, pp. 188–96,35 by permission of Oxford University Press

1. There is a clear sense of affiliation of healthcare professionals to clinical groups and specialties in which they work: that is, the local social network within specialties acts as a strong determinant of antimicrobial prescribing behaviors. Outside of their own autonomous decision making, healthcare professionals are happy to comply with practice that is a marker of their clinical group or identified social network [. . .].

Reproduced from Charani et al. , Understanding the determinants of antimicrobial prescribing within hospitals: the role of prescribing etiquette, Clinical Infectious Diseases, 2013, vol. 57, iss. 2, pp. 188–96,35 by permission of Oxford University Press

Figure 7 provides an illustration of CMOCs 10–13 about responses to perceived patient pressures and to receiving conflicting advice from different health professionals. 10,35,43,56,58,59,62,63,69,70,73,79–81,91,97,98,114–116

FIGURE 7.

Partial programme theory (CMOCs 10–13).

Realist analysis

Relevant extracts from papers included in the review

1. . . . it’s all about the culture of teaching within the firms so it’s about all of the senior doctors not just rushing through a ward round and just shouting out “prescribe this, prescribe that” it’s about them saying “I am thinking of prescribing this and this is my rationale, what do you think” or “let’s go for this because of this – do you understand why I’ve done that?” ’ (Female Foundation Year 2 doctor)

Reproduced from Mattick et al. , A window into the lives of junior doctors: narrative interviews exploring antimicrobial prescribing experiences, Journal of Antimicrobial Chemotherapy, 2014, vol. 69, iss. 8, pp. 2274–8343 by permission of Oxford University Press

1. ‘The fact that I work in an academic facility with residents, fellows, faculty that are always going to ask why did you use that? Why couldn’t you have just used this? That is always staying in the back of my mind that I need to be able to clearly defend my decision to use an antibiotic in a given situation.’ (Attending)

Reproduced with permission from May et al. 10

1. Our study also highlighted the importance of feeling supported and appropriately supervised in building trainees’ confidence. The role of the trainer was pivotal here, with a positive and honest relationship fostering confidence through appropriate support and challenge while effective teaching supported the development of varied consultation skills [. . .]

Data from Wiener-Ogilvie et al. 117

1. Nineteen interviews discussed medical hierarchy, which sometimes worked well, with consultants leading important decision making but enabling juniors to take part.

Reproduced from Mattick et al. , A window into the lives of junior doctors: narrative interviews exploring antimicrobial prescribing experiences, Journal of Antimicrobial Chemotherapy, 2014, vol. 69, iss. 8, pp. 2274–8343 by permission of Oxford University Press

1. Unarticulated rationales for senior clinicians’ prescribing decisions were enormously frustrating and sometimes time-wasting when F[oundation] Y[ear] doctors could not defend decisions made [. . .].

Reproduced from Mattick et al. , A window into the lives of junior doctors: narrative interviews exploring antimicrobial prescribing experiences, Journal of Antimicrobial Chemotherapy, 2014, vol. 69, iss. 8, pp. 2274–8343 by permission of Oxford University Press

1. Clinical supervisors are key and should, we suggest, clarify their expectations in three ways. Firstly, consultants should be explicit about when and whom to ask for help. Secondly, supportive and constructive feedback on all decisions – good, bad and borderline – must accompany the omnipresent ‘reassurance’. Such discussions may lead to detection of near-misses and errors. Most juniors are motivated to learn from error and this reduces their distress. Thirdly, supervisors must ensure that juniors have an appropriate level of confidence and accept an appropriate level of responsibility for errors. Overconfident doctors with low self-criticism may lack insight, be unaware of their limitations and blame others when errors occur, whereas highly self-critical doctors may become disillusioned and depressed after error and grow increasingly detached from patients.

Reproduced with permission from Kroll et al. 118 © Blackwell Publishing Ltd 2008

Realist analysis

Relevant extracts from papers included in the review

1. When confronted, staff members [senior clinicians] acknowledged being of great influence but sometimes giving bad examples [to junior clinicians . . .].

Reproduced from Cortoos et al. , Opposing expectations and suboptimal use of a local antibiotic hospital guideline: a qualitative study, Journal of Antimicrobial Chemotherapy, 2008, vol. 62, iss. 1, pp. 189–95,62 by permission of Oxford University Press

1. Another registrar described an interaction with her supervisor whom she had asked for advice regarding a diagnosis, and then was uncomfortable with their suggestion to prescribe an antibiotic: ‘I think in the back of my mind ‘I don’t know everything, maybe they’ve seen something like this before and it has been bacterial.’ I guess I’m just assuming that they have some kind of clinical knowledge that I don’t.’ (Registrar)

Republished with permission of the Royal College of General Practitioners, from Antibiotic prescribing for the future: exploring the attitudes of trainees in general practice, Dallas et al. , volume 64, 2014;73 permission conveyed through Copyright Clearance Center, Inc.

1. ‘[Doctors] may have more information that I’m not yet aware of which may then mean that actually it is entirely appropriate.’ (Pharmacist, Medicines for the Elderly)

Reproduced from Charani et al. , Understanding the determinants of antimicrobial prescribing within hospitals: the role of ‘prescribing etiquette’, Clinical Infectious Diseases, 2013, vol. 57, iss. 2, pp. 188–96,35 by permission of Oxford University Press

1. They [trainees] are expected to follow the usually unwritten rules of each of their ‘bosses’ and to take instructions. This results in inadequate communication, fragmented supervision, inadequate instructions, and more frequent suboptimal patient outcomes.

Reproduced from Hierarchies: the Berlin Wall of patient safety, Walton et al., vol. 15, pp. 229–30, 200678 with permission from BMJ Publishing Group Ltd

1. ‘. . . a consultant who didn’t come up to the ward . . . when he did come up he was never that fussed if you were with him or not . . . he would just leave you a list of things to do . . . it was a bit disheartening . . . you were never . . . completely reassured about what you were doing . . . you never really get to grips with his actual overall plan . . . so you end up not feeling that important part in a team because it doesn’t matter if you were there or not . . . you’ve to follow blindly what he wrote . . .’ (Male, early-stage medical trainee)

Reproduced from Leadership and followership in the healthcare workplace: exploring medical trainees’ experiences through narrative inquiry, Gordon et al. , vol. 5, e008898, 2015115 with permission from BMJ Publishing Group Ltd

1. Participants reported negative interactions with authority that resulted in a profound loss of commitment. Residents described experiences and personal interactions as profoundly negative, leading to an inability to function and a loss of joy and investment in their work. Also, participants voiced the desire for recognition. They reported their roles being perceived as insignificant, and they felt devalued.

Reprinted from the American Journal of Surgery, volume 210, Bongiovanni T, Yeo H, Sosa JA, Yoo PS, Long T, Rosenthal M, et al. , Attrition from surgical residency training: perspectives from those who left,119 648–54, Copyright 2015, with permission from Elsevier

1. Negative experiences included seniors not being supportive or available, being unnecessarily critical, having unreasonable expectations and undermining confidence [. . .] most comments about hierarchy were negative, with associated poor team relations and treatment delays [. . .].

Reproduced from Mattick et al. A window into the lives of junior doctors: narrative interviews exploring antimicrobial prescribing experiences, Journal of Antimicrobial Chemotherapy, 2014, vol. 69, iss. 8, pp. 2274–8343 by permission of Oxford University Press

1. ‘On the first day of my residency I came in very early, drew up all the medications I thought would be appropriate for the first patient. My staff anesthesiologist came into the OR [Operating Room] and asked if those were my drugs, I said yes. He proceeded to throw them in the garbage and didn’t talk to me until after lunch. That was my first day of residency.’ (Resident)

Reproduced from Canadian Journal of Anaesthesia, Residents’ reluctance to challenge negative hierarchy in the operating room: a qualitative study, vol. 62, 2015, pp. 576–86, Bould et al. ,83 © Canadian Anesthesiologists’ Society. With permission of Springer

Realist analysis

Relevant extracts from papers included in the review

1. Yet, MRs [Medical Residents] argued that it is quite impossible to adequately combine the educational and the professional dimensions of their role. [. . .] Working overload thus makes it difficult to manage the learner and the professional role, and questions their planning efforts. This situation is all the more difficult that it is hardly acknowledged by other health care professionals [. . .].

Reproduced from Advances in Health Sciences Education, Dissonant role perception and paradoxical adjustments: an exploratory study on medical residents’ collaboration with senior doctors and head nurses, vol. 19, 2014, pp. 311–27, Fiordelli et al. ,120 © Springer Science + Business Media Dordrecht 2013. With permission of Springer

1. Teaching sessions were seen as a conflicting priority for trainees and, while they are compulsory sessions, doctors often commented that the subject matter was not relevant to their needs. One doctor said that ‘I was quite disappointed with the teaching programme . . .  much time was given over to audit, ethics, law, protocols etc. . . .  insufficient time [was] spent on learning & developing clinically . . . ’[. . .]. Training was sometimes ‘interrupted by consultant bleeps [beeps/pager alerts] which you cannot reject’ [. . .]. One doctor remarked that the NHS treated junior doctors as ‘service providers, without investing any time in our welfare or future training’ [. . .]. Another felt that doctors ‘must be educated and given the opportunity to develop as doctors, not as a combined clerical and clinical support worker’ [. . .].

Reproduced from Maisonneuve et al. 121 This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated

1. [Residents] expressed concerns about being placed in situations in which inappropriate expectations were being placed on the care that they were going to provide or in which the supervision was inappropriate [. . .].

Data from Hilliard et al. 77

Figure 8 provides an illustration of CMOCs 14–16 on optimal and suboptimal role modelling, including perceptions of trainees about their dual role as both practitioner and learner. 10,35,43,62,63,68,72,73,77,78,81,83,99,115,117–131

FIGURE 8.

Partial programme theory (CMOCs 14–16).

Realist analysis

Relevant extracts from papers included in the review

1. We found that residents in our study were concerned about appearing incompetent in front of those with more power and they were hesitant to communicate information that was unfavorable or negative to themselves. A resident does not want to appear ignorant about a patient. He or she wants to appear knowledgeable about the medical condition and about the patient in particular, and to present pertinent but not unnecessary information. [. . .] ‘You can’t be afraid to or ashamed to ask for help’. (Resident)

Reproduced with permission from Sutcliffe et al. , Communication failures: an insidious contributor to medical mishaps, Academic Medicine, vol. 79, iss. 2, pp. 186–94134

1. There may be uncertainty about local custom and practice, there may be a reluctance to admit ignorance and seek advice, there may be hierarchical obstacles to communication among medical colleagues and in the end the junior doctor may simply take a guess.

Data from Dobrzanski et al. 58

1. The protocol for phoning on-call staff was often unclear (e.g. who to call and what to check first) and sometimes resulted in a reprimand for phoning [. . .] ‘I went to the registrar who wasn’t a renal registrar he was the registrar on-call overnight and he didn’t know so he asked me to phone the microbiologist on-call and this was at about 5 o’clock in the morning and so I had a double check for half an hour and made sure there was nothing in there [the British National Formulary and guidelines] and eventually phoned the microbiologist and I think that she was incredibly angry with me over the phone about me the most junior member of the team was calling her at 5.30 in the morning to ask advice’. (Female Foundation Year 2 doctor)

Reproduced from Mattick et al. , A window into the lives of junior doctors: narrative interviews exploring antimicrobial prescribing experiences, Journal of Antimicrobial Chemotherapy, 2014, vol. 69, iss. 8, pp. 2274–8343 by permission of Oxford University Press

1. The most common reason to use an external resource was for antimicrobial selection, and for this decision prescribers usually consulted with another physician or pharmacist (57 of 81, 70%). The second most common reason was to decide on the proper dose, and for this decision, prescribers usually consulted a nonhuman resource (38 of 55, 69%).

Reproduced from Sellman et al. , Information resources used in antimicrobial prescribing, Journal of the American Medical Informatics Association, 2004, vol. 11, iss. 4, pp. 281–4135 by permission of Oxford University Press

1. [. . .] lack of approachable senior support for inexperienced junior staff [. . .] when you’re starting, it’s really intimidating to try and find the Reg. [Registrar] on-call about what he thinks about their patient, so therefore you kind of leave it and wait for the ward round [. . .]

Reproduced from Barlow et al. 68 This is an open access article distributed under the terms of the Creative Commons CC BY license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited

1. In managing uncertainty, residents report a ‘hierarchy of assistance’, using colleagues and literature for initial management, followed by senior residents, specialty fellows and, finally, the attending physician.

Reproduced from Resident uncertainty in clinical decision making and impact on patient care: a qualitative study, Farnan et al. , vol. 17, pp. 122–6, 2008132 with permission from BMJ Publishing Group Ltd

1. Trainees’ decisions about whether or not to seek clinical support were influenced by three issues: the clinical question (clinical importance, scope of practice), supervisor factors (availability, approachability), and trainee factors (skill, desire for independence, evaluation) [. . .] and the perceived impact of their request on their professional credibility.

Data from Kennedy et al. 133

Figure 9 summarises CMOCs 17–20, consolidating data on assistance-seeking behaviours by doctors in training. 43,58,59,66,68,72,80,81,94,95,116,118,123,124,132–138

FIGURE 9.

Partial programme theory (CMOCs 17–20).

Realist analysis

Relevant extracts from papers included in the review

1. ‘If the attending wants him [the patient] to be on that antibiotic, usually I do not put [forth] a big argument unless I feel very, very strongly. Usually I ask, ‘Why? What is their rationale for being on that antibiotic?’ But if they give a reason I am not going to argue too much’. (Resident interview)

Reproduced with permission from Livorsi et al. 70

1. [M]any residents and staff physicians admitted that they would not provide direct critique of their colleagues’ antibiotic prescribing habits. One commonly cited obstacle to feedback was a respect for hierarchy: ‘If it is another resident in my equal level of training or somebody higher, I would be less inclined to question their antibiotic view’ (resident). [. . .] They did not want to ‘offend’ a colleague or harm a ‘good collegial relationship.’ While a physician’s decision to prescribe an antibiotic may seem questionable in hindsight, participants recognized that the clinical circumstances may have been less clear-cut at the time the decision was made to initiate antibiotics. In addition, critiquing one’s colleagues can be awkward: ‘You’re not going to teach someone who is senior faculty about MICs [minimum inhibitory concentrations] and sensitivities and specificities . . .  or tell them to go back and read a book . . . It’s just not going to happen’. (Staff)

Reproduced with permission from Livorsi et al. 70

1. [. . .] a communication problem exists as a large proportion of residents indicated that their opinion had been discounted before by attendings and that they often would not speak up even though they knew something was wrong.

Reproduced with permission from Belyansky et al. 139

1. One resident told the interviewer of a conversation he had with his father (who was also an anaesthesiologist). Resident: ‘He said to me, the lesson I want you to always learn is that to swallow your pride, just go with whatever they [the consultant anaesthesiologists] say and don’t be argumentative. So, that is definitely always there in the back of my mind’.

Reproduced from Canadian Journal of Anaesthesia, Residents’ reluctance to challenge negative hierarchy in the operating room: a qualitative study, vol. 62, 2015, pp. 576–86, Bould et al. ,83 © Canadian Anesthesiologists’ Society. With permission of Springer

1. [. . .] some saw hierarchy as protecting junior doctors, and therefore facilitating disclosure by some residents, whereas others highlighted how hierarchy inhibits residents from reporting errors committed by attending physicians.

Reproduced with permission from Coffey et al. , Pediatric residents’ decision-making around disclosing and reporting adverse events: the importance of social context, Academic Medicine, vol. 85, iss. 10, pp. 1619–25140

1. Participants perceived a culture in which disagreement or open expression would be frowned on: ‘. . . surgery residency is similar to the military. Everything is really hush, hush. No one wants to tell the truth and be out in the open about what is going on. They want to say what directors want to hear for fear of being stigmatized and being weak. You cannot be seen as weak in a surgery residency, especially as a woman because they will chew you up and spit you out. But because of that you do not feel that you have anyone you can talk to’. (Surgical resident who had left the training programme)

Reprinted from the American Journal of Surgery, volume 210, Bongiovanni T, Yeo H, Sosa JA, Yoo PS, Long T, Rosenthal M, et al. , Attrition from surgical residency training: perspectives from those who left,119 648–54, Copyright 2015, with permission from Elsevier

1. The majority of medical students (85%) and postgraduate trainees (78%) reported difficulty questioning the decisions or actions of those with more authority and approximately two-thirds of medical students and one-third of postgraduate trainees did not feel they could approach someone engaging in unsafe patient care.

Data from Doyle et al. 141

1. [. . .] the inability of trainees to intervene in a setting of a black-and-white scenario with repeated, obvious and life-threatening mistakes is alarming, and this behaviour could translate into ‘real-life’ errors of management.

Reproduced with permission from Friedman et al. 82 © 2015 The Association of Anaesthetists of Great Britain and Ireland

1. The influence of issues such as desire for promotion, approval and appropriate respect for seniority makes it difficult to challenge a superior.

Reproduced with permission from Friedman et al. 82 © 2015 The Association of Anaesthetists of Great Britain and Ireland

1. When issues around challenging authority arise during debriefing discussions, our course participants (anesthesiology residents) often describe perceived barriers to action, including (1) assumed hierarchy, (2) fear of embarrassment of self or others, (3) concern over being misjudged, (4) fear of being wrong, (5) fear of retribution, (6) jeopardizing an on-going relationship, (7) natural avoidance of conflict, and (8) concern for reputation. When these discussions involve the situation of a student challenging a teacher or a mentor, the related issues of (1) respect for the teacher/student relationship, (2) violation of a special trust, (3) high value placed on experience, and (4) concern over being negatively evaluated are often cited. In addition to the psychosocial constraints, our course participants report that not finding the appropriate words or phrasing inhibits their ability to challenge a decision when a concern over patient safety arises.

Reproduced with permission from Pian-Smith et al. , Teaching residents the two-challenge rule: a simulation-based approach to improve education and patient safety, Simulation in Healthcare, vol. 4, iss. 2, pp. 84–91142

Realist analysis

Relevant extracts from papers included in the review

1. [. . .] pre-existing relationships by themselves are not sufficient to create psychological safety on a team; another essential element is trust.

Data from van Schaik et al. 143

1. Other residents cited positive examples from their clinical training where an anesthesia staff was a clear and directive leader in a crisis situation but still listened to feedback and other ideas during the crisis and changed management appropriately as a consequence. They highlighted the importance for the team leader not to consider the challenges to the management plan as a challenge to their position in the hierarchy or to feel the need to become defensive.

Reproduced from Canadian Journal of Anaesthesia, Residents’ reluctance to challenge negative hierarchy in the operating room: a qualitative study, vol. 62, 2015, pp. 576–86, Bould et al. ,83 © Canadian Anesthesiologists’ Society. With permission of Springer

1. Some staff physicians were willing to give feedback to their colleagues about antibiotic choices, but the forum had to be ‘appropriate.’ For example, changeovers were cited as a situation in which this feedback could be given. One staff physician thought the ‘academic’ environment was conducive to educating colleagues [. . .].

Reproduced with permission from Livorsi et al. 70

1. Person 1: ‘It also depends on the staff. The young ones who are fresh out of the system. They remember what it was like to be a resident, you know.’ Person 2: ‘And they’re approachable.’ Person 3: ‘Like, Dr. X. He’s set in his ways and I know I’m on tape [everybody laughs] but he’s not someone who’s going to be receptive to your feedback.’ [Focus group with pediatric residents]

Reproduced with permission from Coffey et al. , Pediatric residents’ decision-making around disclosing and reporting adverse events: the importance of social context, Academic Medicine, vol. 85, iss. 10, pp. 1619–25140

1. Residents’ decisions to question or challenge are affected by the climate of their workplace. Universally, work environments that welcome and foster the ‘speaking up’ of residents encourage learning and a team approach to patient safety.

Reproduced from A cross-cultural survey of residents’ perceived barriers in questioning/challenging authority, Kobayashi et al. , vol. 15, pp. 277–83, 2006144 with permission from BMJ Publishing Group Ltd

1. Issues related to relationship and personalities of superiors affected the willingness of residents to challenge; in fact, this was identified as the most important factor in NOT challenging in both countries.

Reproduced from A cross-cultural survey of residents’ perceived barriers in questioning/challenging authority, Kobayashi et al, vol. 15, pp. 277–83, 2006144 with permission from BMJ Publishing Group Ltd

Realist analysis

Relevant extracts from papers included in the review

1. [W]e found that other residents remained reluctant to seek advice despite simultaneously appreciating that attendings encouraged them to ask for assistance.

Data from Tamuz et al. 116

1. ‘I don’t want to lose respect by asking a stupid question.’ (Resident)

Data from Tamuz et al. 116

1. ‘I mean [the attending] said I could call him in the middle of the night if I needed anything but I am not going to do that . . .  I am not going to wake him up . . .’ [Resident interview]

Reproduced from Resident uncertainty in clinical decision making and impact on patient care: a qualitative study, Farnan et al., vol. 17, pp. 122–6, 2008132 with permission from BMJ Publishing Group Ltd

1. Our results showed no effect of OT [Operating Theatre] team behaviour on the quality of trainees’ challenges towards their consultant anaesthetist in a simulated crisis scenario. Personality type also did not correlate with the quality of the challenge.

Reproduced from Sydor et al. , Challenging authority during a life-threatening crisis: the effect of operating theatre hierarchy, British Journal of Anaesthesia, 2013, vol. 110, iss. 3, pp. 463–71145 by permission of Oxford University Press

Apart from the norms within the wider working and learning environment, the literature also discusses discrepancies between perceptions of doctors in training and consultants regarding accessibility and opportunities to ask questions freely. Senior doctors often seem to be unaware that communication boundaries exist and consider communication norms to be more open than they are perceived to be by doctors in training. They may also be sending contradictory messages between their words and actions. This resonates with the observation that doctors in training may avoid asking questions even if their seniors have signalled that this would be acceptable. Apart from implicit rules in the wider environment taking precedence over individual norms by single consultants, there may also be scope for improving the way accessibility is signalled and challenging is prioritised more concretely to change the overall balance.

Realist analysis

Relevant extracts from papers included in the review

1. In their review, Shreves and Moss reported that medical attending physicians were largely unaware of house staff concerns about patient management issues since these concerns were never brought forth, suggesting that residency directors need to encourage residents to discuss their ethical conflicts with attending physicians [. . .]. Interestingly, while the vast majority of attendings felt that they encouraged residents to speak up when they identified patient safety concerns only half of the residents perceived this to be the case (P < 0.001). In other words, even though attendings expressed the right attitude on this survey, they were not conveying this message clearly to their trainees which again identifies a communication issue.

Reprinted from the Journal of Surgical Research, volume 171, Belyansky I, Martin TR, Prabhu AS, Tsirline VB, Howley LD, Phillips R, et al. Poor resident-attending intraoperative communication may compromise patient safety,139 386–94, Copyright 2011, with permission from Elsevier

1. The perceived patient safety culture varies between trainees and consultants, with more senior staff evaluating the safety culture to be safer than trainees. This effect is most marked between consultants and trainees [. . .] findings in this study suggest that more senior staff might over-estimate the safety of the clinical environment. [. . .] Perhaps most worrying of all is the response to the question ‘My safety concerns would be acted on if I expressed them to management’. Only 2.9% of trainees agreed strongly with this statement compared to 17.9% of consultants.

Reproduced from Bethune et al. , Clinical Risk (vol. 18, iss. 2) pp. 52–7,146 copyright © 2012 by SAGE Publications. Reprinted by permission of SAGE Publications, Ltd

1. Senior doctors and trainee doctors also show a distinction in their perceptions of communication openness between doctors, with senior doctors reporting more positive perceptions.

Data from Reader et al. 147

1. Although the seniors did acknowledge the presence of a hierarchy, they felt that it was confined to surgical specialties, whereas the juniors described it as a barrier to seeking help in all contexts. [. . .] Senior doctors appreciated that juniors found acute situations stressful, but seemed to regard the emotional response as a transient, restrictive state rather than the pervasive, debilitating state described by their junior colleagues [. . .].

Reproduced with permission from Tallentire et al. 72 © Blackwell Publishing Ltd 2011

Figure 10 summarises CMOCs 21–26 on trainee decisions to challenge or not challenge the decisions made by others. 35,56,70,72,77,78,82,83,116,118,119,132,134,139–148

FIGURE 10.

Partial programme theory (CMOCs 21–26).

Realist analysis

Relevant extracts from papers included in the review

1. ‘Working constructively under somebody but if you’re something that you were completely thought was wrong then you don’t necessarily have to do it even though you’re not the leader of the team. Like, as long as you’ve you gone about it appropriately’ (female/medical/early-stage).

Reproduced with permission from Gordon et al. 84 © 2015 John Wiley & Sons Ltd

1. Diplomacy is necessary with patients, relatives and of course colleagues, who very often are older and more experienced than them: ‘You arrive as a MR [Medical Resident], you are young (. . . ). There is people here [the nurses] who have been working for 30 years, they could be your parents. You have to be very patient in the relationships, to show that you are the doctor and it’s your job to take decisions. But at the same time you don’t have to be too extreme and do things on your own. You need a balance. A lot of balance. (. . . ). You’d better not argue with them. (. . . ) You’d better have words in one ear and out from the other, otherwise you go crazy. This is stressing . . . You have to be tactful, patient.’ [Medical Resident, female]

Reproduced from Advances in Health Sciences Education, Dissonant role perception and paradoxical adjustments: an exploratory study on medical residents’ collaboration with senior doctors and head nurses, vol. 19, 2014, pp. 311–27, Fiordelli et al. ,120 © Springer Science + Business Media Dordrecht 2013. With permission of Springer

1. ‘It never happens to me; I always get approvals (smiling). Just change the fields (patients’ parameters) a bit and you know you get what you want.’ [Junior Medical Staff]

Data from Zaidi and Thursky98

1. A delicate balance between taking responsibility and being supported was necessary to achieve the dual aims of intern development and patient care. This balance shifted over time, as the interns developed.

Reproduced from Advances in Health Sciences Education, Participation and progression: new medical graduates entering professional practice, vol. 16, 2011, pp. 627–42, Bearman et al. ,81 © Springer Science + Business Media B.V. 2011. With permission of Springer

1. However, a number of participants reported that this anxiety around uncertainty decreased over time as they began to understand that managing uncertainty is a normal part of being a doctor: ‘I think there’s a lot of uncertainty and at first I think I found it quite difficult, you know wanting to find an answer for everything [. . .] but I know that it’s not possible and I think that’s fine to say that you don’t know [. . .] And I think, yeah I guess I am finding that easier [. . .] I think I am coming to realise that medicine is full of uncertainties.’ (Foundation Year 1 doctor)

Reproduced with permission from Brennan et al. 136 © Blackwell Publishing Ltd 2010

1. However, the quality of challenges did improve with increasing level of training (PGY) [Postgraduate Year]. Final-year trainees’ challenges tended to be at a relatively high level, such as the use of an advocacy-inquiry technique, attempting to take over the case, or at least repeated use of advocacy or inquiry with initiation of discussion [. . .].

Reproduced from Sydor et al. , Challenging authority during a life-threatening crisis: the effect of operating theatre hierarchy, British Journal of Anaesthesia, 2013, vol. 110, iss. 3, pp. 463–71145 by permission of Oxford University Press

Figure 11 brings together the CMOCs for changing contexts, with the mechanisms and outcomes associated to training progression and willingness to negotiate prescribing decisions under certain circumstances. 63,76,77,81,84,98,116,120,136,145

FIGURE 11.

Partial programme theory (CMOCs 27 and 28).

Producing stakeholder-relevant knowledge

Discussions with stakeholders (see Chapter 2, Stakeholder group for more details) helped to contextualise the knowledge acquired through the synthesis, taking into account barriers and facilitators that health professionals and patients had identified through their own experiences. For example, one of the things that was extensively discussed in the stakeholder meetings was disciplinary differences in prescribing habits and openness to receiving advice from other specialists. These discussions also helped in understanding how the training environment has recently changed for trainees (e.g. workload pressures or availability of guidelines in mobile applications) and how these changes have shaped their attitudes and practices.

Adapting knowledge to local context

The methodological approach used in this review (i.e. realist review) places primary emphasis on actionable findings that can lead to context-sensitive change. Departing from a one-size-fits-all approach, we developed high-level principles that can be tailored to different environments to fit different needs, using examples to help visualise possible scenarios. These principles were then presented in the form of non-academic outputs, aiming to help practitioners better tailor interventions for the specific needs of doctors in training, outlined as follows.

• We have developed an infographic as a concise and visual decision support aid (Figure 13). This infographic points to the principles and processes that need to be considered when designing and implementing an antimicrobial prescribing intervention for doctors in training, as identified in this review. These principles are generic enough to allow local tailoring for different environments. Local stakeholders will be able to select knowledge that is relevant to their local context and to use the infographic as a guide to tailor and critically implement an intervention in a way that is context sensitive and appropriate for trainees at different levels. For example, the infographic asks if the intervention ‘makes AMR everyone’s business’. This means that the wider clinical team needs to be engaged with this issue, rather than just focusing on doctors in training. As a high-level principle, this will be implemented differently in different settings, but the aim would remain the same.

• We have also developed an animation video (see Report Supplementary Material 1) that can be used as part of undergraduate or postgraduate training to trigger reflection and discussion on antimicrobial prescribing. Our stakeholder group identified hospital induction as a particular opportunity for more engaging ways of ‘setting a culture’ around ‘AMR being everyone’s business.’ Existing educational materials and training programmes cover a substantial amount of technical knowledge and address questions on local processes for prescribing, but do not refer to the sociocultural influences on the prescribing process. This video was developed to prepare doctors in training for engaging with the sociocultural dynamics and the hierarchies that characterise antimicrobial prescribing in different settings. It highlights situations where, for example, junior trainees may not understand what their consultant is prescribing and why, and invites them to consider what they would do to clarify the prescribing rationale and maximise their learning. Propositions made in the video summarise the findings of this review that are relevant to doctors in training and are intended as a useful background for discussion (with the ability to pause the video) tailored to the environment where the video is being used.

FIGURE 13.

High-level principles.

Assessing barriers to knowledge use

Through the review we have identified a number of barriers to knowledge use for the improvement of antimicrobial prescribing. One of the most important barriers to knowledge use is the influence of hierarchical dynamics on antimicrobial prescribing of doctors in training. Hence, we have primarily focused the review on how hierarchical dynamics influence doctors in training to follow the prescribing practices of their seniors. This includes following senior attitudes to guideline acceptance and responding to patient expectations. Although there is significant evidence on how to improve antimicrobial prescribing, it would be difficult to implement this in practice without meaningful and effective senior involvement and/or endorsement. To surface this issue and provide outputs that are simple enough yet also capture its complexities, we needed to develop accessible materials. Our infographic and animation video are intended as tools that can help to surface the importance of hierarchical dynamics for practitioners and give them the decision support or learning opportunities to tackle this issue, thus addressing one of the barriers to knowledge use. However, possible limitations remain as these resources are developed for use in advanced health-care systems, rather than in low- and middle-income countries where barriers to appropriate prescribing and training environments may differ radically.

The following sections discuss actionable findings emerging from the synthesis of the literature and present the dissemination materials developed as part of the IMPACT review for practitioners and policy-makers.

Strategy

1. ((junior or train*) adj2 (doctor* or medic* or physician*)).tw.

2. (“foundation year 1” or “foundation year 2” or “foundation year one” or “foundation year two” or registrar* or “new prescriber*”).tw.

3. ((f1 or f2 or fy1 or fy2) adj3 (doctor* or medic* or physician*)).tw.

4. (foundation adj3 (doctor* or medic* or physician*)).tw.

5. ((SpR or SpRs) adj10 (doctor* or medic* or physician*)).tw.

6. GPST.tw.

7. (“pre-registration house officer*” or “senior house officer*” or “house officer*”).tw.

8. ((resident* or residenc*) adj2 (doctor* or medic* or physician*)).tw.

9. PRHO.tw.

10. ((HO or SHO) adj3 (doctor* or medic* or physician*)).tw.

11. ((intern or interns or internship*) and (doctor* or medic* or physician*)).tw.

12. “Internship and Residency”/

13. or/1-12

14. (prescrib* or prescrip*).tw.

15. ((drug* or medicine* or medication*) adj2 (administ* or utili?ation or error*)).tw.

16. exp prescription/

17. exp Drug Utilization/

18. Prescription Drugs/

19. Drug Prescriptions/

20. Medication Errors/

21. or/14-20

22. (antimicrobial* or “anti microbial*” or antibiotic* or “anti biotic*” or antibacterial* or “anti bacterial*” or antiviral* or “anti viral*” or antifungal* or “anti fungal*” or “antiinfective*” or “anti infective*” or antiparasitic* or “anti parasitic*”).tw.

23. anti-infective agents/

24. exp anti-bacterial agents/

25. exp antifungal agents/

26. exp anti-infective agents, urinary/

27. exp antiparasitic agents/

28. exp antiviral agents/

29. or/22-28

30. 13 and 21 and 29

Strategy

1. ((junior or train*) adj2 (doctor* or medic* or physician*)).tw.

2. (“foundation year 1” or “foundation year 2” or “foundation year one” or “foundation year two” or registrar* or “new prescriber*”).tw.

3. ((f1 or f2 or fy1 or fy2) adj3 (doctor* or medic* or physician*)).tw.

4. (foundation adj3 (doctor* or medic* or physician*)).tw.

5. ((SpR or SpRs) adj10 (doctor* or medic* or physician*)).tw.

6. GPST.tw.

7. (“pre-registration house officer*” or “senior house officer*” or “house officer*”).tw.

8. ((resident* or residenc*) adj2 (doctor* or medic* or physician*)).tw.

9. PRHO.tw.

10. ((HO or SHO) adj3 (doctor* or medic* or physician*)).tw.

11. ((intern or interns or internship*) and (doctor* or medic* or physician*)).tw.

12. or/1-11

13. (prescrib* or prescrip*).tw.

14. ((drug* or medicine* or medication*) adj2 (administ* or utili?ation or error*)).tw.

15. or/13-14

16. (antimicrobial* or “anti microbial*” or antibiotic* or “anti biotic*” or antibacterial* or “anti bacterial*” or antiviral* or “anti viral*” or antifungal* or “anti fungal*” or “antiinfective*” or “anti infective*” or antiparasitic* or “anti parasitic*”).tw.

17. 12 and 15 and 16

Strategy

1. ((junior or train*) adj2 (doctor* or medic* or physician*)).tw.

2. (“foundation year 1” or “foundation year 2” or “foundation year one” or “foundation year two” or registrar* or “new prescriber*”).tw.

3. ((f1 or f2 or fy1 or fy2) adj3 (doctor* or medic* or physician*)).tw.

4. (foundation adj3 (doctor* or medic* or physician*)).tw.

5. ((SpR or SpRs) adj10 (doctor* or medic* or physician*)).tw.

6. GPST.tw.

7. (“pre-registration house officer*” or “senior house officer*” or “house officer*”).tw.

8. ((resident* or residenc*) adj2 (doctor* or medic* or physician*)).tw.

9. PRHO.tw.

10. ((HO or SHO) adj3 (doctor* or medic* or physician*)).tw.

11. ((intern or interns or internship*) and (doctor* or medic* or physician*)).tw.

12. “interns and residents”/

13. residency education/

14. or/1-13

15. (prescrib* or prescrip*).tw.

16. ((drug* or medicine* or medication*) adj2 (administ* or utili?ation or error*)).tw.

17. prescription/

18. drug utilization/

19. Prescription Drugs/

20. Drug Prescriptions/

21. medication error/

22. or/15-21

23. (antimicrobial* or “anti microbial*” or antibiotic* or “anti biotic*” or antibacterial* or “anti bacterial*” or antiviral* or “anti viral*” or antifungal* or “anti fungal*” or “antiinfective*” or “anti infective*” or antiparasitic* or “anti parasitic*”).tw.

24. exp antiinfective agent/

25. or/23-24

26. 14 and 22 and 25

Strategy

1. ((junior or train*) adj2 (doctor* or medic* or physician*)).tw.

2. (“foundation year 1” or “foundation year 2” or “foundation year one” or “foundation year two” or registrar* or “new prescriber*”).tw.

3. ((f1 or f2 or fy1 or fy2) adj3 (doctor* or medic* or physician*)).tw.

4. (foundation adj3 (doctor* or medic* or physician*)).tw.

5. ((SpR or SpRs) adj10 (doctor* or medic* or physician*)).tw.

6. GPST.tw.

7. (“pre-registration house officer*” or “senior house officer*” or “house officer*”).tw.

8. ((resident* or residenc*) adj2 (doctor* or medic* or physician*)).tw.

9. PRHO.tw.

10. ((HO or SHO) adj3 (doctor* or medic* or physician*)).tw.

11. ((intern or interns or internship*) and (doctor* or medic* or physician*)).tw.

12. medical internship/

13. medical residency/

14. or/1-13

15. (prescrib* or prescrip*).tw.

16. ((drug* or medicine* or medication*) adj2 (administ* or utili?ation or error*)).tw.

17. prescription drugs/

18. exp “Prescribing (Drugs)”/

19. or/15-18

20. (antimicrobial* or “anti microbial*” or antibiotic* or “anti biotic*” or antibacterial* or “anti bacterial*” or antiviral* or “anti viral*” or antifungal* or “anti fungal*” or “antiinfective*” or “anti infective*” or antiparasitic* or “anti parasitic*”).tw.

21. 14 and 19 and 20

Strategy

1. TOPIC: ((junior or train*) near/1 (doctor* or medic* or physician*))

2. TOPIC: (“foundation year 1” or “foundation year 2” or “foundation year one” or “foundation year two” or registrar* or “new prescriber*”)

3. TOPIC: ((f1 or f2 or fy1 or fy2) near/2 (doctor* or medic* or physician*))

4. TOPIC: (foundation near/2 (doctor* or medic* or physician*))

5. TOPIC: ((SpR or SpRs) near/9 (doctor* or medic* or physician*))

6. TOPIC: (GPST)

7. TOPIC: ((“pre-registration house officer*” or “senior house officer*” or “house officer*”))

8. TOPIC: ((resident* or residenc*) near/1 (doctor* or medic* or physician*))

9. TOPIC: (PRHO)

10. TOPIC: ((HO or SHO) near/2 (doctor* or medic* or physician*))

11. TOPIC: ((intern or interns or internship*) and (doctor* or medic* or physician*))

12. #11 OR #10 OR #9 OR #8 OR #7 OR #6 OR #5 OR #4 OR #3 OR #2 OR #1

13. TOPIC: ((prescrib* or prescrip*))

14. TOPIC: ((drug* or medicine* or medication*) near/1 (administ* or utili?ation or error*))

15. #14 OR #13

16. TOPIC: (antimicrobial* or “anti microbial*” or antibiotic* or “anti biotic*” or antibacterial* or “anti bacterial*” or antiviral* or “anti viral*” or antifungal* or “anti fungal*” or “antiinfective*” or “anti infective*” or antiparasitic* or “anti parasitic*”)

17. #16 AND #15 AND #12

Strategy

1. ((junior or train*) near/2 (doctor* or medic* or physician*)):ti or ((junior or train*) near/2 (doctor* or medic* or physician*)):ab

2. (“foundation year 1” or “foundation year 2” or “foundation year one” or “foundation year two” or registrar* or “new prescriber*”):ti or (“foundation year 1” or “foundation year 2” or “foundation year one” or “foundation year two” or registrar* or “new prescriber*”):ab

3. ((f1 or f2 or fy1 or fy2) near/3 (doctor* or medic* or physician*)):ti or ((f1 or f2 or fy1 or fy2) near/3 (doctor* or medic* or physician*)):ab

4. (foundation near/3 (doctor* or medic* or physician*)):ti or (foundation near/3 (doctor* or medic* or physician*)):ab

5. ((SpR or SpRs) near/10 (doctor* or medic* or physician*)):ti or ((SpR or SpRs) near/10 (doctor* or medic* or physician*)):ab

6. GPST:ti or GPST:ab

7. (“pre-registration house officer*” or “senior house officer*” or “house officer*”):ti or (“pre-registration house officer*” or “senior house officer*” or “house officer*”):ab

8. ((resident* or residenc*) near/2 (doctor* or medic* or physician*)):ti or ((resident* or residenc*) near/2 (doctor* or medic* or physician*)):ab

9. PRHO:ti or PRHO:ab

10. ((HO or SHO) near/3 (doctor* or medic* or physician*)):ti or ((HO or SHO) near/3 (doctor* or medic* or physician*)):ab

11. ((intern or interns or internship*) and (doctor* or medic* or physician*)):ti or ((intern or interns or internship*) and (doctor* or medic* or physician*)):ab

12. MeSH descriptor: [Internship and Residency] this term only

13. or #1-#12

14. (prescrib* or prescrip*):ti or (prescrib* or prescrip*):ab

15. ((drug* or medicine* or medication*) near/2 (administ* or utili?ation or error*)):ti or ((drug* or medicine* or medication*) near/2 (administ* or utili?ation or error*)):ab

16. MeSH descriptor: [Prescriptions] explode all trees

17. MeSH descriptor: [Drug Utilization] explode all trees

18. MeSH descriptor: [Prescription Drugs] this term only

19. MeSH descriptor: [Drug Prescriptions] this term only

20. MeSH descriptor: [Medication Errors] this term only

21. or #14-#20

22. (antimicrobial* or “anti microbial*” or antibiotic* or “anti biotic*” or antibacterial* or “anti bacterial*” or antiviral* or “anti viral*” or antifungal* or “anti fungal*” or “antiinfective*” or “anti infective*” or antiparasitic* or “anti parasitic*”):ti or (antimicrobial* or “anti microbial*” or antibiotic* or “anti biotic*” or antibacterial* or “anti bacterial*” or antiviral* or “anti viral*” or antifungal* or “anti fungal*” or “antiinfective*” or “anti infective*” or antiparasitic* or “anti parasitic*”):ab

23. MeSH descriptor: [Anti-Infective Agents] this term only

24. MeSH descriptor: [Anti-Bacterial Agents] 1 tree(s) exploded 

25. MeSH descriptor: [Antifungal Agents] 1 tree(s) exploded

26. MeSH descriptor: [Anti-Infective Agents, Urinary] explode all trees

27. MeSH descriptor: [Antiparasitic Agents] 1 tree(s) exploded

28. MeSH descriptor: [Antiviral Agents] 1 tree(s) exploded

29. 77-#28

30. #13 and #21 and #29

Strategy

1. TI,AB(((junior OR train*) NEAR/1 (doctor* OR medic* OR physician*)) OR “foundation year 1” OR “foundation year 2” OR “foundation year one” OR “foundation year two” OR registrar* OR “new prescriber*” OR ((f1 OR f2 OR fy1 OR fy2) NEAR/2 (doctor* OR medic* OR physician*)) OR (foundation NEAR/2 (doctor* OR medic* OR physician*)) OR ((SpR OR SpRs) NEAR/9 (doctor* OR medic* OR physician*)) OR GPST OR “pre-registration house officer*” OR “senior house officer*” OR “house officer*” OR ((resident* OR residenc*) NEAR/1 (doctor* OR medic* OR physician*)) OR PRHO OR ((HO OR SHO) NEAR/2 (doctor* OR medic* OR physician*)) OR ((intern OR interns OR internship*) AND (doctor* OR medic* OR physician*))) OR SU.EXACT.EXPLODE(“House officers” OR “Preregistration house officers” OR “Senior house officers”) OR SU.EXACT(“Senior registrars”) OR SU.EXACT(“Registrars”)

2. TI,AB((prescrib* OR prescrip*) OR (drug* OR medicine* OR medication*) NEAR/1 (administ* OR utili?ation OR error*)) OR SU.EXACT(“Prescriptions”)

3. TI,AB(antimicrobial* or “anti microbial*” or antibiotic* or “anti biotic*” or antibacterial* or “anti bacterial*” or antiviral* or “anti viral*” or antifungal* or “anti fungal*” or “antiinfective*” or “anti infective*” or antiparasitic* or “anti parasitic*”) OR SU.EXACT(“Antibiotics”) OR SU.EXACT(“Antiviral drugs”) OR SU.EXACT.EXPLODE(“Anthelmintics” OR “Antiparasitic agents”)

4. 1 AND 2 AND 3

Strategy

1. (authority or “senior staff” or “senior doctor*” or hierarch* or nonhierarch*).tw.

2. Hierarchy, Social/

3. or/1-2

4. (team* or interpersonal* or interprofessional*).tw.

5. (role* adj2 responsibil*).tw.

6. Interprofessional Relations/

7. Interpersonal Relations/

8. or/4-7

9. decision*.tw.

10. exp Decision Making/

11. or/9-10

12. 8 or 11

13. (trainee* or (train* adj2 program*)).tw.

14. (“junior doctor*” or intern* or residen*).tw.

15. “Internship and Residency”/

16. or/13-15

17. 3 and 12 and 16

Strategy

1. (authority or “senior staff” or “senior doctor*” or hierarch* or nonhierarch*).tw.

2. (team* or interpersonal* or interprofessional*).tw.

3. (role* adj2 responsibil*).tw.

4. or/2-3

5. decision*.tw.

6. 4 or 5

7. (trainee* or (train* adj2 program*)).tw.

8. (“junior doctor*” or intern* or residen*).tw.

9. 7 or 8

10. 1 and 6 and 9

Strategy

1. (authority or “senior staff” or “senior doctor*” or hierarch* or nonhierarch*).tw.

2. dominance hierarchy/

3. or/1-2

4. (team* or interpersonal* or interprofessional*).tw.

5. (role* adj2 responsibil*).tw.

6. interpersonal relationships/

7. or/4-6

8. decision*.tw.

9. exp Decision Making/

10. or/8-9

11. 7 or 10

12. (trainee* or (train* adj2 program*)).tw.

13. (“junior doctor*” or intern* or residen*).tw.

14. medical internship/

15. medical residency/

16. or/12-15

17. 3 and 11 and 16

Strategy

1. authority or “senior staff” or “senior doctor*” or hierarch* or nonhierarch*:ti or authority or “senior staff” or “senior doctor*” or hierarch* or nonhierarch*:ab in Cochrane Reviews (Reviews and Protocols), Trials and Technology Assessments 

2. MeSH descriptor: [Hierarchy, Social] explode all trees 

3. #1 or #2

4. team* or interpersonal* or interprofessional*:ti or team* or interpersonal* or interprofessional*:ab in Cochrane Reviews (Reviews and Protocols), Trials and Technology Assessments

5. role* near/2 responsibil*:ti or role* near/2 responsibil*:ab in Cochrane Reviews (Reviews and Protocols), Trials and Technology Assessments

6. MeSH descriptor: [Interprofessional Relations] explode all trees 

7. MeSH descriptor: [Interpersonal Relations] explode all trees

8. (57-#7)

9. decision*:ti or decision*:ab in Cochrane Reviews (Reviews and Protocols), Trials and Technology Assessments

10. MeSH descriptor: [Decision Making] explode all trees

11. #9 or #10

12. #8 or #11

13. trainee* or (train* near/2 program*):ti or trainee* or (train* near/2 program*):ab in Cochrane Reviews (Reviews and Protocols), Trials and Technology Assessments

14. “junior doctor*” or intern* or residen*:ti or “junior doctor*” or intern* or residen*:ab in Cochrane Reviews (Reviews and Protocols), Trials and Technology Assessments

15. MeSH descriptor: [Internship and Residency] this term only

16. {or #13-#15}

17. #3 and #12 and #16

Strategy

(ti(authority OR “senior staff” OR “senior doctor*” OR hierarch* OR nonhierarch*) OR ab(authority OR “senior staff” OR “senior doctor*” OR hierarch* OR nonhierarch*)) AND (((ti(team* OR interpersonal* OR interprofessional*) OR ab(team* OR interpersonal* OR interprofessional*)) OR (ti(role* NEAR/1 responsibil*) OR ab(role* NEAR/1 responsibil*)) OR SU.EXACT(“Interpersonal relationships”)) OR ((ti(Decision*) OR ab(Decision*)) OR SU.EXPLODE(“Decision making”))) AND ((ti(trainee* OR (train* NEAR/1 program*)) OR ab(trainee* OR (train* NEAR/1 program*))) OR (ti(“junior doctor*” OR intern* OR residen*) OR ab(“junior doctor*” OR intern* OR residen*)) OR SU.EXACT(“Internships”) OR SU.EXPLODE(“House officers”))