title: Unwrapping the diagnosis of tuberculosis in primary care: a qualitative study.
abstract: BACKGROUND
  Although tuberculosis (TB) is relatively rare in the UK, its diagnosis is important because diagnostic delays can result in worse outcomes for patients and expose others to the risk of infection. Atypical presentations may be common, and patients' help-seeking behaviour may influence the diagnostic process in primary care. Little is known about the process of diagnosing TB in primary care in developed countries.
  
  
  OBJECTIVE
  To understand the process of diagnosing TB in UK primary care.
  
  
  METHODS
  Qualitative inductive study with paired semi-structured interviews.
  
  
  METHODS
  Communities and general practices in south-east Wales.
  
  
  METHODS
  Interviews were conducted with 17 patients diagnosed with TB in the previous 6 months and 16 GPs involved with their care. Data were analysed thematically.
  
  
  RESULTS
  In response to expected classical features, GPs generally ordered specific tests. Both GPs and patients reported atypical presentations, and then the diagnostic and referral net was appropriately widened in most cases. Identified barriers to prompt diagnosis included atypical presentations and low clinical suspicion of TB, lack of continuity of care, workload demands that limit time with patients, and suboptimal clinician-patient communication. GPs recognised the growing problem of TB nationally and the need for improved education among health professionals.
  
  
  CONCLUSIONS
  GPs' and patients' accounts about the process of diagnosing TB suggest that delays can occur, although they are not typical. Where diagnosis is clear, GPs generally test specifically and refer appropriately; where diagnosis is less clear, the diagnostic net is cast further. It is only when certain core values of general practice are not applied (including continuity of care, considering context appropriately, and eliciting and responding appropriately to patients' explanatory models) that clinicians and patients identify a suboptimal diagnostic process.
authors.affiliation: Department of General Practice, Centre for Health Sciences Research, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff, Wales. metcalfep@cf.ac.uk
authors.forename: Elizabeth P
authors.initials: EP
authors.lastname: Metcalf
authors.forename: Joanne C
authors.initials: JC
authors.lastname: Davies
authors.forename: Fiona
authors.initials: F
authors.lastname: Wood
authors.forename: Christopher C
authors.initials: CC
authors.lastname: Butler
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D001294:Attitude to Health; D003937:Diagnosis, Differential; D042241:Early Diagnosis; D005194:Family Practice; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians'; D036301:Qualitative Research; D012017:Referral and Consultation; D012307:Risk Factors; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000209:etiology; D014852:Wales