Table 3 Sub-themes relating to support structures in place to guide decision-making

Consult with senior

… if you’re unsure you will tend to have more in-depth conversation with them about, ‘look I’m really not sure’. Sometimes they’ll actually go and see the patient and decide and sometimes they’ll just have a longer chat with you about what you think. P2 R

Generally, CT scans for head, or C-spine, we are recommended to often talk to the consultant before we order them, so we get a second opinion before we order them, because of the high risk of radiation. Yes, so we will make the initial decision, because we've seen the patient, we [worked] them up from point A to point B, but we always like to get a confirmation from the consultant. P9 I

Consult with radiology staff

(registrar/

radiologist/

radiographer)

There's been many discussions with radiology registrars, especially on night shifts, around whether or not to do scans. P5 R

I've been relying on them [radiology registrar] a lot more to help that decision-making because there are times when I would want to order something and they say ‘no, that's not appropriate’ or ‘that's not going to show you anything or a CT is not going to help in your management, it's not going to change your management’. P11 I

Model consultants and more experienced doctors

We see that amongst consultants, as well. Especially things like one of the criteria is if a patient has a painful distracting injury, probably one of the most equivocally applied criteria in NEXUS, some consultants will think of it as if a patient's distracted. Others will think of it as if the patient, either the patient has a distracting injury, regardless of whether they're distracted by it or not. That difference in opinion is very common amongst senior doctors. As junior doctors, we often listen, wonder why the consultant thinks so. Often, they will apply their experience, more so than the criteria. P9 I

Ongoing training

There is one big period in an emergency trainee’s life, particularly in Australia … is when you study for your Fellowship exams, it does change significantly the way you practice. Because up until that point you can be a very good clinician, you can be a very experienced clinician, but you only realise when you study for that exam, the knowledge that you’re missing. And that does inform, I think – there’s several things, not even that I’ve purposely changed, but having the background knowledge of a specialty training exam, a consultancy does make a difference in that respect. P15 C

Clinical decision support tools

But where I would use it is in those middling patients, where I’m not sure. P15 C

it's a matter of incorporating both the experience and decision rules. At this moment, at this point in time, as a junior doctor, I trust the decision rules more than I trust my experience, because due to lack of my experience at this stage. P9 I

The clinical decision-making tools do two things; I think they can confirm what you're thinking, so they can support your professional opinion, but they can also help as a checkpoint to make you rethink what you're doing as well. P18 R