Objective Examine clinical reasoning and decision making in an out of hours (OOH) primary care setting to gain insights into how general practitioners (GPs) make clinical decisions and manage risk in this environment.
Design Semi-structured interviews using open-ended questions.
Setting A 2-month qualitative interview study conducted in Oxfordshire, UK.
Participants 21 GPs working in OOH primary care.
Results The most powerful themes to emerge related to dealing with urgent potentially high-risk cases, keeping patients safe and responding to their needs, while trying to keep patients out of hospital and the concept of ‘fire fighting’. There were a number of well-defined characteristics that GPs reported making presentations easy or difficult to deal with. Severely ill patients were straightforward, while the older people, with complex multisystem diseases, were often difficult. GPs stopped collecting clinical information and came to clinical decisions when high-risk disease and severe illness requiring hospital attention has been excluded; they had responded directly to the patient's needs and there was a reliable safety net in place. Learning points that GPs identified as important for trainees in the OOH setting included the importance of developing rapport in spite of time pressures, learning to deal with uncertainty and learning about common presentations with a focus on critical cues to exclude severe illness.
Conclusions The findings support suggestions that improvements in primary care OOH could be achieved by including automated and regular timely feedback system for GPs and individual peer and expert clinician support for GPs with regular meetings to discuss recent cases. In addition, trainee support and mentoring to focus on clinical skills, knowledge and risk management issues specific to OOH is currently required. Investigating the stopping rules used for diagnostic closure may provide new insights into the root causes of clinical error in such a high-risk setting.
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Review history and Supplementary material
To cite: Balla J, Heneghan C, Thompson M, et al. Clinical decision making in a high-risk primary care environment: a qualitative study in the UK. BMJ Open 2012;2:e000414. doi:10.1136/bmjopen-2011-000414
Contributors JB designed the study, conducted the interviews, analysed the data and produced the first draft to final document. CH and MT conceived the project and were involved with design and all stages of writing the drafts and final document. MB participated in the interviews and analysis as well as reviewing the drafts and final document.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None.
Ethics approval This is a quality improvement study involving volunteer general practitioners who cannot be identified.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The original transcripts are available.
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