title: GPs' perspectives on the diagnostic work-up in patients with shoulder pain: a qualitative study.
abstract: OBJECTIVE
  The diagnostic work-up of patients with shoulder pain in general practice is complex. General practitioners' (GPs) guidelines advise a pragmatic diagnostic work-up in which additional imaging has a limited role. However, diagnostic ultrasounds are increasingly ordered by GPs, which seems to reflect complexity in management of shoulder pain. This study aimed to explore GPs' perspectives on the diagnostic work-up of patients with shoulder pain.
  
  
  METHODS
  This study has a qualitative exploratory design with an inductive approach and was carried out in Dutch general practice. The study population consisted of 18 Dutch GPs who were sampled purposefully with a spread in clinical experience and ordering diagnostic ultrasound. Data were gathered by means of semi-structured interviews and analysed following principles of the constant comparative method.
  
  
  RESULTS
  Three main categories with subcategories emerged that captured the diagnostic work-up of shoulder pain: variety in diagnostic classifications [(non-)specific diagnosis and interdisciplinary differences], establishing strategies for diagnostic work-up (use of existing tools and motives to deviate from existing tools), and strategies dealing with diagnostic uncertainties (accepting diagnostic uncertainties, diagnostic imaging tests, and interdisciplinary consultation and referral).
  
  
  CONCLUSIONS
  Despite the availability of evidence-based shoulder guidelines, GPs experience uncertainties during diagnostic work-up and apply different strategies when dealing with these uncertainties. At some point, GPs as well as patients seem to have a need for a specific diagnosis. Currently, there appears to be little agreement if, or in which phase of shoulder pain, diagnostic ultrasound is useful or indicated.
authors.affiliation: Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.
authors.forename: Ramon P G
authors.initials: RP
authors.lastname: Ottenheijm
authors.forename: Nicolle J J M
authors.initials: NJ
authors.lastname: Hesselmans
authors.forename: Anouk
authors.initials: A
authors.lastname: Kemper
authors.forename: Albine
authors.initials: A
authors.lastname: Moser
authors.forename: Rob A
authors.initials: RA
authors.lastname: de Bie
authors.forename: Geert-Jan
authors.initials: GJ
authors.lastname: Dinant
authors.forename: Jochen W L
authors.initials: JW
authors.lastname: Cals
mesh_terms: D003937:Diagnosis, Differential; D005260:Female; D058005:General Practitioners / Q000523:psychology; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D009426:Netherlands; D010818:Practice Patterns, Physicians'; D036301:Qualitative Research; D020069:Shoulder Pain / Q000000981:diagnostic imaging*; D014463:Ultrasonography
keywords: classification; diagnosis; general practice; qualitative research; shoulder pain; ultrasound