De-Contextualised Risk Information in the Primary Care Consultation

Background Primary care diagnosis is conducted under conditions of uncertainty, as the primary inputs-patient history and examination-are variable, contextual, and often ambiguous. This process is susceptible to bias and diagnostic errors. One method employed to mitigate the risk of overlooking significant diagnoses is the use of routine clinical scores or risk assessment tools. These tools provide clinicians with information on potential high-risk diagnoses, often without a direct request from the clinician. This PhD dissertation examines how this information, referred to as “Decontextualised Risk Information” (DRI), influences clinical decision-making and how primary care clinicians process and communicate this information during consultations. Methods A systematic review and qualitative synthesis of Electronic Risk Assessment Tools (eRATs), as an example of DRI in primary care diagnosis, was undertaken. A qualitative study involving general practitioners (GPs) who had utilised an eRAT as part of the ERICA trial (an ongoing clinical trial investigating the effectiveness of eRATs for cancer diagnosis in primary care) was performed. It explored, through qualitative methods, how eRATs influenced the GPs' clinical decision-making in real-world settings. A third study expanded and further explored the concept and impact of DRI in clinical consultations. This study presented clinical vignettes in which DRI conflicted with the clinicians' working diagnoses. The clinicians were interviewed, and qualitative methods were employed to analyse the data. Results DRI can suggest diagnoses that clinicians might otherwise overlook. However, DRI can also complicate the clinical consultation process, can instil fear or uncertainty in both clinicians and patients, potentially dominating the consultation. It may undermine the clinical autonomy of the clinician and lead to defensive medical practices. Conclusion DRI in the form of clinical scores and risk assessment tools has the potential to enhance patient care. While research has primarily focused on identifying predictive factors and developing these tools and scores, this thesis suggest that the intended consequences of DRI, in the form of supporting the diagnostic process, may be undermined by the added uncertainty, fear and defensive medicine created by it. More focus and attention is needed on these unintended consequences of DRI on decision-making and human behaviour. Further research is necessary to explore how such tools can be effectively integrated into clinical consultations to maximise their benefits while minimising potential harms. More research is needed to build on the work of this thesis, to help us understand the boundaries of a clinician’s and patient’s epistemic authority when external sources of data are introduced into a consultation. Models of how to integrate DRI into a consultation need to be developed and evaluated, to help train future clinicians.<p></p>

Author dc:creator

• Alex Burns (21052766)

• Diagnosis
• Uncertainty
• Electronic Risk Assessment
• Primary Care
• General Practice
• Decontextualised Risk Information

Statement dc:rights

• All rights reserved

Identifier

10779/exe.32248296.v1

OAI identifier oai:identifier

oai:figshare.com:article/32248296