Family Practice Vol. 20, No. 5, 514-519
© Oxford University Press 2003
The consultation |
Use of rules of thumb in the consultation in general practice—an act of balance between the individual and the general perspective
a Centre for Clinical Research, Nissers väg 3, 791 82 Falun,
b Department of Health and Society, Primary Care, Faculty of Health Sciences, Linköping University, 581 85 Linköping and
c Unit of Research and Development in Primary Care, 551 85 Jönköping, Sweden.
Correspondence to M André; E-mail: Malin.Andre{at}ltdalarna.se
André M, Borgquist L and Mölstad S. Use of rules of thumb in the consultation in general practice—an act of balance between the individual and the general perspective. Family Practice 2003; 20: 514–519.
Received 4 November 2002; Revised 25 April 2003; Accepted 19 May 2003.
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Abstract |
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Background. Rules of thumb used by GPs could be considered as empirical evidence of intuition and a link between science and practice in general practice.
Objective. The purpose of the present study was to analyse the description of the application of rules of thumb with regard to different situations in general practice.
Methods. An explorative and descriptive study was started with focus group interviews. Four groups with 23 GPs were interviewed. The interviews were transcribed and analysed, and the rules and their application were classified by an editing analysis.
Results. A specific set of rules of thumb was used for rapid assessment, when emergency and psychosocial problems were identified. When the main focus of the problems was identified as somatic or psychosocial, the GPs did not disregard the other aspects but described the use of rules in a simultaneous individualizing and generalizing process. The rules contained probability reasoning and risk assessment.
Conclusion. Rules of thumb seemed to serve as a link between theoretical knowledge and practical experience and were used by the GPs in an act of balance between the individual and the general perspective.
Keywords. Consultation, focus groups, general practice, heuristics.
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Introduction |
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General practice is characterized by the work of the GP in the front line of healthcare.1 The initial task in the consultation is 2-fold: to understand the patient’s experience of the illness and to categorize the patient’s illness into a diagnosis.2 This is described as the art of general practice, and Malterud claims that it should be defined as the successful interrelationship between the biomedical and humanistic perspective in clinical practice.3,4 Gaining this skill is the challenge of general practice, but only a few succeed.5,6 Rules of thumb used by GPs could be considered as empirical evidence of intuition and a link between science and practice, expressing some of the essence of clinical knowledge in general practice.7
Rules of thumb, which are called heuristics in cognitive psychology, are used in more automatic mental processes and are described as mental shortcuts that lessen mental strain. Heuristics are considered useful and even necessary shortcuts, guiding search and choice in uncertainty and under time constraint.8 Since rules of thumb used by GPs have not been described previously, an exploratory study was started with focus groups. In a previous report, the identified rules of thumb were described and categorized in two groups: rules for somatic and psychosocial problems.9
The present study aimed to analyse the interviews on the application of the rules with regard to different situations in consultations in primary care.
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Methods |
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In the year 2000, about half of the 140 GPs in Dalarna in Sweden participated in seven groups of continuing medical education, and all groups were invited to participate. One group declined and four groups were interviewed. Recruiting of new groups was stopped when few new examples of rules arose.10 The groups worked in different parts of the county and comprised between four and seven GPs. The 23 participating GPs, 10 females and 13 males, had all worked in general practice for between 5 and 20 years. The moderator (MA) was acquainted with all the 23 participating GPs.
In the interviews, the moderator introduced the subject and presented the concept ‘rule of thumb’, defined as an action-oriented mental pattern, used during the consultation whether or not the background for the rule was understood and should not be based on prior knowledge of the patient. She also gave two examples of her own: ‘When a patient can bear weight on a leg it is not broken’ and ‘When a rapid streptococcal test is positive, prescribe phenoxymethylpenicillin.’ A guide for the interview had been created beforehand containing the questions: Do you recognize the use of rules of thumb? Are you able to give some examples? What are the benefits and dangers of using rules of thumb? Where do they come from? In the discussion, which lasted for 60–90 min, the moderator followed the guide, confirmed statements and asked for clarifications. The discussions went on freely after the first minutes of hesitation, and every group expressed their satisfaction after the session.
The interviews were audiotaped, transcribed verbatim and analysed with principles for systematic, qualitative analysis.10 The statements were shortened, rephrased, put in an ordinary Word file and ordered manually. The different examples of rules were classified using an editing (inductive) analysis procedure.10 The coding procedure was carried out stepwise. As the rules were categorized for either somatic or psychosocial problems, they were coded in relation to the description of when they were used during the consultation. The concepts and their relationships were confirmed, modified or discarded during a repeated analysis of the shortened statement and the transcribed interviews. The categorization was discussed between the authors until agreement was reached. In order to validate the result, the study was discussed at seminars with the interviewed GPs.
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Results |
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Specific rules were identified which were used for a rapid assessment of the consultation, which implied a rough sorting into one of three situations: emergency, somatic or psychosocial. In the further consultation process, the GPs alternated between rules for somatic and psychosocial problems in a generalizing and individualizing way, which was influenced by the assessment of risk. The rapid assessment was described as a process with time constraint in contrast to the following process of the consultation, where rules of thumb were used in an iterative way irrespective of time.
Rules for rapid assessment
Specific sets of rules were used in the beginning of the consultation for a rough, rapid assessment of the situation taking into account both emergency and psychosocial problems (Table 1
). This first classification determined the further route of the consultation as the GPs adjusted their work to the setting. One GP stated that this assessment "determined which rules you adopt". The GPs exemplified this adjustment of work according to emergency or psychosocial problems.
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"I try to get a feeling for how serious it is. If I see from the beginning that this is something I can’t handle and should be sent on to the hospital, then I keep the rest of the consultation rather short because then it’s ... a question of getting the foundation for a well done sensible referral as quickly as possible and getting the patient transported.""In other contexts ... these much more complex situations—why are you coming in now and why do you have these problems—then it’s a matter of creating an understanding for the patient ... And then of course it’s another type of work one has to do."
Sometimes the rapid assessment was recognized as an unconscious process (Table 1
:1). Although the GPs were aware of these early judgements of the situation, they could not always verbalize which explicit criteria they used when they identified an emergency situation or psychosocial problems.
"How do you assess whether a patient is seriously ill? What do we look at? We don’t have to put them on their legs. I guess it is something with the look on their faces."
Rules used to individualize and to generalize
The remaining rules of thumb covered the different steps in a consultation: investigation, diagnosis and treatment (Table 2). Most of the rules concerned somatic problems and most diagnostic rules were formulated as necessary criteria to be fulfilled or not, rendering yes or no answers (Table 2:3–5). In this way, the problem was dichotomized. The rules for psychosocial problems differed from the rules for somatic problems in that they were expressed as memos, rules for investigation and diagnosis were combined and few rules for treatment were identified (Table 2:8–11).
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The GPs gave examples of how they alternated between rules for somatic and psychosocial problems, thus alternating between a generalizing, biomedical approach and an individualizing, patient-centred approach (Fig. 1
). In consultations where a somatic problem was identified, the GPs postulated rules used to individualize the consultation, e.g. to always ask for the patient’s own ideas or to come to terms with the patient before the consultation ended (Table 2:12–13). The GPs also gave examples of rules used in connection with specific somatic problems to reveal the patient’s emotions and worries (Table 2: 14–15). When the problem was identified as psychosocial, the GPs would ensure that they did not miss a somatic disorder by using rules for investigation of somatic problems (Table 2:16).
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The rules expressed not only the likelihood for disorder but also the assessment of risk. Some rules aimed to minimize the risk of missing a serious disorder, as wide criteria for inclusion were used (Table 1
:2), thus the GPs took pay off into account."But I don’t just go for likelihoods; instead, I imagine that it could possibly be something horrible ... that’s how you want to investigate even though the likelihood is small, right? And begin rather quickly with it in any case."
On the other hand, some rules expressed the aim to secure the identification of the really sick patients with a calculated risk of failure to include every single one. This was exemplified by the use of the anamnesis to screen patients with vertigo (Table 2:5). The assessment of risk influenced the relative preference given to the generalizing and the individualizing process. When the GP considered the risk of a serious somatic disease to be high, they tended to individualize the consultation less, and no examples were given of rules used to individualize the consultation in an emergency situation (Table 1:1–4). When the GPs judged the risk of a potentially disabling disorder to be low, they gave more room for the individualizing process.
"All that with rapid StrepA test and sore throat. You can get well without antibiotics. Sometimes I don’t care about testing and learn from the patient what it has been like."
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Some specific features in primary care consultation emerged in this study of rules of thumb. A specific set of rules was used for rapid assessment and notification of emergency and psychosocial problems. When the main focus of the problems was identified as somatic or psychosocial, the GPs did not disregard the other aspects but described the use of rules in a simultaneous individualizing and generalizing process. The rules expressed everyday use of risk assessment with the use of probabilistic reasoning.
The study has some limitations. The problems with focus group interview and coding analysis were discussed in the previous report.9 Most rules concerning psychosocial problems emerged from one of the focus groups, although they were also recognized by GPs from the other groups in subsequent meetings. No effort was made to obtain examples of rules valid for every step in a consultation, and thus the description applies only for fragments of the GP’s work. The initial examples given by the moderator concerned rules for somatic problems, which might have influenced the subsequent discussion and the examples gathered. Our results are context bound to Sweden today, where primary care is characterized, for example, by a low rate of encounter with a GP, only half of that in Great Britain. Most interviewed GPs were educated in the 1970s and 1980s when lessons in patient-centred consultation were not given. Moreover, the consultation is an interactive process between doctor and patient, and this study only considers the view of the doctors. Nevertheless, confronted with the results of the study in subsequent seminars, GPs recognized features of their everyday work very well.
The study of problem solving is difficult and the research is often carried out by multi-professional teams with the use of a combination of different methods. Video-recordings combined with interviews of the GP are acknowledged as the most valid method by many researchers.11 Focus groups were used, as they are well suited in an initial exploratory study to gather information.12 One further advantage of asking for rules of thumbs in a setting of colleagues is that theorizing immediately would be recognized. The study was set up to describe the rules of thumb of the GPs and not primarily their application, which is why recruiting of new focus groups was stopped when the material seemed saturated in terms of examples of rules of thumb and not their application. However, in spite of the shortcomings of the study, the results highlight vital areas and might serve to generate some hypotheses for further research.
Rapid assessment
The GPs described the first rough assessment as an immediate, almost unconscious process (Table 1:1). The GPs’ difficulty in characterizing the specific criteria used to identify the emergency situation has been described previously.13 Although this first assessment of the present situation seems like common sense, it is not the usual way to describe the problem-solving process in general practice.2,14 However, when GPs describe their clinical method based on their own experience, the descriptions are similar. McWhinney describes the use of clinical dichotomies as a starting point in the diagnostic process, e.g. urgent–not urgent or physical pathology– no physical pathology,2 and Morrell writes that the first stage of the diagnostic process is to identify serious life-threatening disease.3
When the GPs described sorting out emergency and psychosocial problems, there was a tacit understanding that somatic problems were the expected, normal state. This may explain why GPs often do not elicit patients’ unspoken worries, although about one-third of the consultations have been classified as psychosocial and have health-affecting psychosocial problems.5,15 The initial rapid assessment seems to be crucial and may be one factor in explaining doctors’ different working styles.5,6
The individual and the general disorder
The differentiation between somatic and psychosocial problems relates to the philosophical discussion of medicine as a science of diseases or a practice involving persons with illnesses, sometimes described as medicine as science and medicine as art. The GPs described how they did not abandon either the somatic or the psychosocial focus.
The different stress laid on the generalizing and the individualizing process, illustrated in Figure 1, corresponds to the classical description of doctor-centred or patient-centred consultations.6 Thus, rules of thumb may be another way to study the same phenomena, where the rules guide the GP in the attempt to manage the consultation. In psychosocial problems, the patient is the expert from whom the GP must learn more, whereas in somatic problems, the GP is the expert. However, this reasoning presumes that GPs change their working style according to the problems patients present, but the individual GP tends to keep their own pattern of work independently of the situation.5,6
The patient-centred method has come to be an acknowledged method during the last decades. Several studies and books describe the consultation but omit the description of the biomedical process.16,18 However, some authors equally emphasize differentiating items for the medical decision and the use of a patient-centred method for communication.3,19 In this study, these seem to be combined and equally important, which is in accordance with a study of GPs in The Netherlands. Among the studied GPs, the performance of obligatory physical examination and paying attention to psychosocial matters were positively correlated, thus the behavioral and medical skills were related and equally developed.20
When rules of thumb were used, problem solving was characterized by a stepwise simplification and narrowing of the problem. This is in contrast to the classical description of problem solving in consultation (the hypothetico-deductive method), which assumes a scientific method, where the GP creates a hypothesis from patient cues and tests this hypothesis.2,14 Further research has questioned this description and, instead, knowledge-driven problem solving has been revealed, where the expert in their clinical reasoning uses schemes specific to the problems in their domains. The availability and order of knowledge determine the usefulness of the expert reasoning.19 The rapid assessment of emergency and psychosocial problems as well as separate rules for somatic and psychosocial problems could be part of the tailored scheme and expert knowledge used by the experienced GP. In contrast to a deductive strategy, where the singular event is predicted from general laws, this is an inductive process, reasoning from a singular event.
Many problems in primary care are minor illnesses that are resolved without a definitive diagnosis, and the task of the GP is to rule out any serious disease.3,17 In this process, the GP has to balance the risk of missing a serious, somatic disease against the risk of somatic fixation of psychosocial problem caused by superfluous investigations.20 Many rules were expressions of risk assessment, and it seems that risk avoidance concerning somatic disease influenced the work of the GPs, whereas the risk of somatic fixation was not correspondingly spoken about. One explanation could be the influence of the introductory somatic examples of rules of thumb given by the moderator.
In conclusion, this study showed that the GPs started the consultation with a rough assessment of the situation, when emergency and psychosocial problems were identified. In the further process, they alternated between a somatic and psychosocial approach in an act of balance between the individual and the general perspective. The rules of thumb seemed to serve as a link between theoretical knowledge and practical experience. The rules contained probability reasoning and risk assessment. As the characteristics of consultation revealed by this study have not been described previously, they need to be confirmed by further research, taking into account that choice of method is a determining factor for the results obtained. Moreover, studies that link rules of thumb to intermediate outcomes in the consultation as well as explore the individual variations of rules of thumb would be of interest.
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Acknowledgments |
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We wish to thank all interviewed colleagues. This study was funded with research grants from the Dalarna Research Institute, Center for Clinical Research and the County of Dalarna, Sweden.
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