Worked Examples: Disagreement About a Clinical Decision

Clinical disagreements are among the highest-stakes SJT scenarios. They test whether you can advocate for patient safety while respecting the team structure. These scenarios are deliberately designed to create tension between following hierarchy and protecting patients.

This lesson works through detailed clinical disagreement scenarios with full option analysis.

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The Core Decision Framework

When you disagree with a clinical decision, ask yourself three questions:

Question	If YES	If NO
Is patient safety at risk?	You must raise your concern, regardless of who made the decision	Consider whether it is a matter of preference or approach rather than safety
Have I raised my concern directly?	If dismissed, escalate	Raise it directly first — this is almost always the required first step
Am I qualified to assess this?	Express your concern clearly and specifically	Express your concern but acknowledge your limitations

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Scenario 1: Wrong Drug, Right Intentions

You are a medical student on a respiratory ward. The FY1 prescribes amoxicillin for a patient with a documented penicillin allergy. You notice the allergy on the patient's wristband and in the notes.

Option Analysis

Option	Rating	Reasoning
A: Tell the nurse administering the medication about the allergy	Appropriate, but not ideal	This prevents the immediate harm, but does not address the prescribing error with the prescriber. The nurse should check, but you should also speak to the FY1
B: Speak to the FY1 immediately: "I noticed this patient has a penicillin allergy documented. The prescription is for amoxicillin — could we check this?"	Very appropriate	Direct, immediate, factual, and non-confrontational. Amoxicillin is a penicillin, so this is a genuine safety concern
C: Say nothing because you are only a medical student and might be wrong	Very inappropriate	The allergy is documented. This is not a matter of clinical judgement — it is a clear safety issue. Medical students have a duty to speak up
D: Go straight to the consultant to report the FY1's error	Inappropriate, but not awful	Over-escalation. The FY1 should be given the opportunity to correct the error first. If they refuse or are unavailable, the registrar or consultant is appropriate

Key Learning

• A documented drug allergy is a clear, objective safety concern — there is no ambiguity
• Speaking to the prescriber directly is almost always the correct first step
• Medical students are never too junior to raise a factual safety concern
• Informing the nurse is a reasonable safety net but does not replace speaking to the prescriber

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Scenario 2: Disagreement About Discharge Timing

You are an FY1 on a surgical ward. The registrar decides to discharge Mr Thompson, an 82-year-old who had a hip replacement two days ago. You are concerned because Mr Thompson has not been mobilised by physiotherapy, lives alone, and told you this morning that he feels dizzy when he stands.

Option Analysis

Option	Rating	Reasoning
A: Accept the registrar's decision without comment because they are more senior	Inappropriate	While the registrar is more senior, you have patient-reported information (dizziness on standing) that may not have been considered. Staying silent could lead to an unsafe discharge
B: Approach the registrar and share your concerns: "I wanted to mention that Mr Thompson told me he feels dizzy on standing, and I do not think physio have assessed him yet. Could we review before discharge?"	Very appropriate	Assertive, respectful, factual. You are sharing specific observations and requesting a review
C: Tell the patient not to worry and that you will try to delay the discharge	Inappropriate	This undermines the registrar's decision without discussing it with them. It also makes promises you may not be able to keep
D: Call the consultant to overrule the registrar	Inappropriate, but not awful	You have not yet spoken to the registrar about your concerns. This bypasses the appropriate person

Why This Scenario Is Challenging

The registrar is more experienced and may have good reasons for the discharge decision (bed pressure, the patient's own wishes, clinical stability). But you have information they may not have:

• The patient reports dizziness on standing (possible postural hypotension)
• Physiotherapy has not assessed mobilisation
• The patient lives alone (falls risk at home)

The SJT does not expect you to overrule the registrar. It expects you to share relevant information respectfully so the registrar can make a fully informed decision.

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Scenario 3: Disagreement About Investigation

You are an FY2 in A&E. A patient presents with severe headache and neck stiffness. Your colleague (also an FY2) wants to send the patient home with painkillers. You are concerned about meningitis.

Option Analysis