Article Text


Are more experienced clinicians better able to tolerate uncertainty and manage risks? A vignette study of doctors in three NHS emergency departments in England
  1. Rebecca Lawton1,2,
  2. Olivia Robinson3,
  3. Rebecca Harrison3,
  4. Suzanne Mason4,
  5. Mark Conner3,
  6. Brad Wilson5
  1. 1 Institute of Psychological Sciences, University of Leeds, Leeds, UK
  2. 2 Quality and Safety Research, Bradford Institute for Health Research, Bradford, UK
  3. 3 School of Psychology, University of Leeds, Leeds, UK
  4. 4 School of Health and Related Research, University of Sheffield, Sheffield, UK
  5. 5 Accident and Emergency, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
  1. Correspondence to Dr Rebecca Lawton, Institute of Psychological Sciences, University of Leeds, Leeds LS2 9JT, UK; r.j.lawton{at}


Background Risk aversion among junior doctors that manifests as greater intervention (ordering of tests, diagnostic procedures and so on) has been proposed as one of the possible causes for increased pressure in emergency departments (EDs). Here we tested the prediction that doctors with more experience would be more tolerant of uncertainty and therefore less risk-averse in decision making.

Methods In this cross-sectional, vignette-based study, doctors working in three EDs were asked to complete a questionnaire measuring experience (length of service in EDs), reactions to uncertainty (Gerrity et al, 1995) and risk aversion (responses about the appropriateness of patient management decisions).

Results Data from 90 doctors were analysed. Doctors had worked in the ED for between 5 weeks and 21 years. We found a large association between experience and risk aversion so that more experienced clinicians made less risk-averse decisions (r=0.47, p<0.001). We also found a large association between experience and reactions to uncertainty (r=−0.50, p<0.001), with more experienced doctors being much more at ease with uncertainty. Mediation analyses indicated that tolerance of uncertainty partially mediated the relationship between experience and lower risk aversion, explaining about a quarter of the effect.

Conclusion While we might be tempted to conclude from this research that experience and the ability to tolerate uncertainty lead to positive outcomes for patients (less risk-averse management strategies and higher levels of safety netting), what we are unable to conclude from this design is that these less risk-averse strategies improve patient safety.

  • decision making
  • emergency department
  • cognitive biases
  • patient safety

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

Statistics from


  • Contributors The study idea came from a discussion between RL, BW and SM. The study was designed by RL, RH and OR, with input from BW and SM who helped develop the study materials. Data were collected by RH and OR, who also sought permissions for the study. Data collection was supported by BW and SM. RL input data, conducted analyses and produced the first draft of the manuscript. MC reanalysed the data after reviewers' comments and edited the entire manuscript to account for the different approach to analysis. He also produced the table and the figure. This final version was then edited and approved by all other authors.

  • Funding This research was supported by the National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC) and the NIHR CLAHRC Yorkshire and Humber. The views expressed in this article are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval was obtained through the University of Leeds, Faculty of Medicine and Health (ethics reference: 17–0160; 26 May 2017). Following this, Health Research Authority approval was sought and granted (IRAS ID 226846; 27 July 2017).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles