title: To refer or not to refer: a qualitative study of reasons for referral from Role 1.
abstract: OBJECTIVE
  There are currently over 9000 British soldiers serving in Afghanistan. The Defence Medical Services provide primary health care to soldiers at forward locations using Regimental Medical Officers (RMOs) and General Duties Medical Officers (GDMOs). If required, GDMOs can refer patients to senior colleagues. Currently, little is known about the reasons for referrals by GDMOs. This study aims to identify the main factors affecting why GDMOs refer from forward locations.
  
  
  METHODS
  Nine GDMOs, who deployed on Operation HERRICK 13, were invited to join the study. They maintained a log of their referrals for two 14 day periods, one in each half of their tour. In addition, a semi-structured interview was performed with each GDMO in order to elicit the common themes surrounding referrals.
  
  
  RESULTS
  The mean referral rate was 0.9 referrals/GDMO/week. The main reasons for referral were dental problems, musculoskeletal injuries, abdominal pain of unknown cause, and ano-genital problems. Factors that influenced referrals included availability of forwardly projected services (dentist and physiotherapist), manpower availability at the locations, the availability of flights (affected by weather, enemy action, and schedule of routine flights), and the timing of the tour in relation to leave.
  
  
  CONCLUSIONS
  Referrals from GDMOs were due to doctor inexperience in the treatment of a particular condition, lack of access to investigations and the potential for deterioration in a location without adequate support. The referral decision process was affected by the patient's importance with regards to the mission, the weather and access to safe transportation. The introduction of clinical guidelines for common conditions in conjunction with minor alterations to GDMO training could help reduce referrals from Role 1, preserving manpower, reducing costs, and minimising risk to evacuation aircraft.
authors.affiliation: GDMO 5 Medical Regiment, Gaza Barracks, Catterick. jamiedriver@doctors.org.uk
authors.forename: J M
authors.initials: JM
authors.lastname: Driver
authors.forename: T G
authors.initials: TG
authors.lastname: Nelson
authors.forename: R
authors.initials: R
authors.lastname: Simpson
authors.forename: C
authors.initials: C
authors.lastname: Wall
mesh_terms: D055826:Afghan Campaign 2001-; D003657:Decision Making; D006801:Humans; D008887:Military Medicine / Q000379:methods*; D008889:Military Personnel; D011320:Primary Health Care / Q000379:methods*; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D006113:United Kingdom