How decontextualised risk information affects clinicians’ understanding of risk and uncertainty in primary care diagnosis: a qualitative study of clinical vignettes

Background: Decontextualised risk information (DRI) is any information pertaining to diagnosis, which is introduced into a clinical consultation, or a diagnostic thought process, without being requested by the clinician. It can be risk scores, computerised warnings, or laboratory tests or diagnostic imaging requests ordered by other clinicians. It is an increasing, and yet under-researched phenomena in UK primary care. Aim: To investigate how GPs integrate DRI into their clinical decision making and how might they communicate this to patients. Design & setting: Clinical vignettes of cases that involve DRI, designed to increase the diagnostic uncertainty of the case, were presented to UK trained GPs. 'Think-aloud' techniques and qualitative interviews were used to explore clinical thinking. Method: Nine GPs were interviewed. After a warmup vignette, clinicians were shown and asked to talk through three clinical vignettes, which involved DRI. Semi-structured interview questions, exploring diagnostic thinking and uncertainty, followed each vignette. Thematic analysis was used to explore the research question. Results: DRI tends to dominate a consultation when introduced. It can produce cognitive dissonance, defensive medicine, and more complex consultations. DRI explicitly presents differential diagnoses that clinicians may have considered but not discussed, compelling them to act, or justify their inaction, at several levels. Clinicians needed to recognise the complexity of clinical reasoning, and balance this against over-reliance on individual test or risk scores. Conclusion: When DRI conflicts with a clinician’s judgement, it can produce cognitive dissonance leading to complex consultations and predisposes towards defensive medical practices.