Table 4

Process of reasoning in this context. Question: Can you describe what was the main driver of the process? Often these statements were made spontaneously during the interview. (Digit after stop refers to 1st or 2nd case for interviewee.)

ThemesExample
Clarify issues and whose agenda to deal with first
  • S: think firstly you have to identify what the real issue is (6.1);

  • D: firstly, what real issue is, in OOH may be very problematic (1.2); too vague to formulate any thoughts (4.2);

Looking for critical cues and red flags
  • S: my main concern then was about her hydration (15.1);

  • D: Especially fast resp rate without infection (1.2); wanted to establish that she was not confused (2.2);

Process of ruling out serious illness first
  • S: I sort of work backwards rather than forwards and so I want to rule out the serious things (16.2); I want to make sure they are systemically well (15.1);

  • D: First thing was likely to be the usual just rule out anything serious (1.1);

Process of ruling in common and safe condition
  • S: rule in, since nil high risk (4.1); purpose was to confirm the diagnosis which she had given me looking for evidence to support…hypothesis (12.1);

  • D: initially I started with a net looking for the common causes (17.2); getting to the correct diagnosis and keeping her safe (20.2);

Reassure patient and carers
  • S: addressing the patient's concerns (15.1);

  • D: my main concern was safety,…how could I keep her as safe as possible while trying to respect her autonomy (10.2);

Risk assessment
  • S: [ketotic pregnant woman]: probably 90% certain that it was a urine infection, I would say 100% certain in this particular case that admission was needed (13.) ; I was just slightly concerned that he was starting something more serious so I said if his temperature went up persistently…or if he became breathless…he should contact back again and that there was somebody on the out of hours all weekend (14.1);

  • D: err on the side of caution…threshold to me feels like a fairly nebulous thing…the clinical state of the patient was surprisingly good (5.2); I was reasonably confident…there was this possibility that we would be able to [treat] her orally (11.2);

Used another opinionwell I actually got somebody else in to have a look at it (7.2); speaking to the medical registrar at the hospital…the other deciding factor (10.2);