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.
Semi-structured interviews using open-ended questions.
A 2-month qualitative interview study conducted in Oxfordshire, UK.
21 GPs working in OOH primary care.
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.
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.
Clinical reasoning and decision making in an out of hours (OOH) primary care setting.
The aim is to gain insights into how general practitioners (GPs) make clinical decisions and manage risk in this environment.
Implications for system changes and training.
Clinical decision making in OOH is dominated by rule-out strategies for severe illness or potentially high-risk diseases.
GPs use three main criteria to determine diagnostic closure: global wellness with rule-outs, responded to patient needs, presence of a reliable safety net.
Improvements to clinical decision making could be achieved by providing routine feedback to clinical staff working in OOH, building in systems to support reflection on clinical cases and more tailored GP training.
Strengths and limitations of this study
The design of the study is based on a strong theoretical framework provided by the dual theory of cognition.
Face validity through using recently seen cases.
Limitations relate primarily to sampling, participants consisting of self-selected individuals.