RT Journal Article
SR Electronic
T1 Clinical decision making in a high-risk primary care environment: a qualitative study in the UK
JF BMJ Open
JO BMJ Open
FD British Medical Journal Publishing Group
SP e000414
DO 10.1136/bmjopen-2011-000414
VO 2
IS 1
A1 John Balla
A1 Carl Heneghan
A1 Matthew Thompson
A1 Margaret Balla
YR 2012
UL http://bmjopen.bmj.com/content/2/1/e000414.abstract
AB 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.