Exploring GPs’ prioritisation dilemmas — ‘quick wins’ versus ‘eating the frog’: a qualitative study in primary care

Andrew McClarey; Agata Dunsmore; Duncan McNab; Samantha Eve Smith

doi:10.3399/BJGP.2025.0628

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Exploring GPs’ prioritisation dilemmas — ‘quick wins’ versus ‘eating the frog’: a qualitative study in primary care
Jonathan A. Sunkersing

Published on: 17 September 2026
The role of uncertainty in clinical prioritisation.
Yulia Chechelnitskaya and Scott Hainey

Published on: 17 September 2026
Continuity as an epistemic resource for prioritisation
Koki Kato

Published on: 03 September 2026

Published on: (17 September 2026)
Page navigation anchor for Exploring GPs’ prioritisation dilemmas — ‘quick wins’ versus ‘eating the frog’: a qualitative study in primary care
Exploring GPs’ prioritisation dilemmas — ‘quick wins’ versus ‘eating the frog’: a qualitative study in primary care
Jonathan A. Sunkersing, GP and Sleep Medicine doctor, The Red House Surgery, Cambridge
McClarey and colleagues describe GPs consciously choosing between quick wins and the deferred difficult task or "frogs". Their SEIPS framing places the clinician in the "person" box, and participants' accounts of self-care suggest factors before preceding consultations. These should include the preceding night's sleep.

Several studies suggest that prescribing behaviour changes across the session. However, the evidence is not conclusive, but the question is at least being asked.

What is not being asked is what the clinician brought into the room at 08:00. Short sleep degrades the functions prioritisation requires: working memory, inhibitory control, affective appraisal. It plausibly also degrades insight into that degradation. A GP deciding which frog to eat may be least able to judge their own capacity to judge, on precisely the mornings when it matters most.

This has a practical consequence for the authors' method. Tactical Decision Games are a good elicitation tool and a natural vehicle for a variable nobody records. Stratifying responses by prior sleep, or by whether the participant tending to a crying child the night before, would cost little and would test whether prioritisation style is a stable disposition or a transient state.

I raise it because variation in clinical decisions is routinely attributed to the population being seen. Some of it may belong to the person deciding.

Competing Interests: None declared.
Published on: (17 September 2026)
Page navigation anchor for The role of uncertainty in clinical prioritisation.
The role of uncertainty in clinical prioritisation.
Yulia Chechelnitskaya, GP, Medical Education Fellow, Medical Educational Directorate, NHS Lothian
Other Contributors:
Scott Hainey, Medical Education Fellow
We read with interest the study by McClarey et al., which identified specific themes influencing GP prioritisation decisions: system awareness, time management, familiarity with patients, patient-doctor relationships, and personal preferences.¹ We suggest that clinical and organisational uncertainty may represent a common thread underlying these themes, given the diagnostic ambiguity, incomplete information, variable service availability, uncertain future workload, and unpredictable patient trajectories that characterise primary care.

The tools described by the participants - reviewing records to reduce anxiety about missing important information, drawing on familiarity with patients to make quicker decisions, relying on clinical expertise, and using knowledge of local services – can be interpreted as mechanisms for reducing uncertainty and enabling prioritisation decisions to be made with greater confidence.

The differing approaches described by participants in this study, including “eating the frog” and pursuing “quick wins”, may also reflect individual differences in tolerance of ambiguity. While uncertainty arises from the situation itself, tolerance of ambiguity reflects how comfortably clinicians function when information is incomplete or indeterminate.² Individual differences in tolerance of ambiguity may, therefore, contribute to variation in prioritisation strategies.

Our interpre...
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We read with interest the study by McClarey et al., which identified specific themes influencing GP prioritisation decisions: system awareness, time management, familiarity with patients, patient-doctor relationships, and personal preferences.¹ We suggest that clinical and organisational uncertainty may represent a common thread underlying these themes, given the diagnostic ambiguity, incomplete information, variable service availability, uncertain future workload, and unpredictable patient trajectories that characterise primary care.

The tools described by the participants - reviewing records to reduce anxiety about missing important information, drawing on familiarity with patients to make quicker decisions, relying on clinical expertise, and using knowledge of local services – can be interpreted as mechanisms for reducing uncertainty and enabling prioritisation decisions to be made with greater confidence.

The differing approaches described by participants in this study, including “eating the frog” and pursuing “quick wins”, may also reflect individual differences in tolerance of ambiguity. While uncertainty arises from the situation itself, tolerance of ambiguity reflects how comfortably clinicians function when information is incomplete or indeterminate.² Individual differences in tolerance of ambiguity may, therefore, contribute to variation in prioritisation strategies.

Our interpretation is supported by the wider literature. Making triage decisions requires clinicians to allocate finite resources according to perceived clinical need, often before complete information is available.³ Clinical uncertainty, including uncertainty regarding prognosis and future outcomes, is widely recognised as an inherent feature of decision making and may influence assessment of urgency and prioritisation.⁴

McClarey et al. highlighted the importance of developing competency in prioritisation for GP registrars. We suggest that training in recognising and managing uncertainty may be equally important, and that many prioritisation skills may emerge from developing these capabilities. Exploring the relationship between uncertainty management and prioritisation may therefore represent a useful direction for future educational research.

References

1. McClarey A, Dunsmore A, McNab D, Smith SE. Exploring GPs' prioritisation dilemmas: 'quick wins' versus 'eating the frog': a qualitative study in primary care. Br J Gen Pract. 2026;76(770):e763-e770.

2. Han PKJ. Uncertainty in Medicine: A Framework for Tolerance. New York: Oxford University Press; 2021.

3. Rodrigues D, Kreif N, Saravanakumar K, Delaney B, Barahona M, Mayer E. Formalising triage in general practice towards a more equitable, safe, and efficient allocation of resources. BMJ. 2022;377:e070757.

4. Bierer BE, Truog RD. The unresolved challenge of triage. JAMA Netw Open. 2023;6(8):e2329676.
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Competing Interests: None declared.
Published on: (3 September 2026)
Page navigation anchor for Continuity as an epistemic resource for prioritisation
Continuity as an epistemic resource for prioritisation
Koki Kato, GP, Madoka Family Clinic
McClarey and colleagues provide a valuable account of prioritisation as more than simply deciding which patient should be seen first on the basis of clinical urgency.¹ Their findings show how experienced GPs draw on system awareness, time, familiarity and relationships when deciding what needs attention, when, and in what form. These findings give language to something I have often experienced in general practice: prioritisation rarely depends on clinical urgency alone.

I am particularly interested in the role of familiarity and therapeutic relationships. Knowing a patient appears to provide more than additional information. In the example of a patient with COPD, the GP can ask whether the current illness feels as severe as a previous admission and judge how much weight to place on that response. The meaning of what is said in the present encounter is therefore shaped by a history of previous encounters.

This can be understood through the phenomenological account offered by Benner and Wrubel ², who emphasise that people make sense of present situations through their past experience. What a patient says now is not interpreted in isolation: previous encounters provide a background against which the present situation is understood. Continuity therefore does more than increase how much a GP knows about a patient; it can change how presently available information is interpreted. A similar process appears in interprofessional relationships,...
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McClarey and colleagues provide a valuable account of prioritisation as more than simply deciding which patient should be seen first on the basis of clinical urgency.¹ Their findings show how experienced GPs draw on system awareness, time, familiarity and relationships when deciding what needs attention, when, and in what form. These findings give language to something I have often experienced in general practice: prioritisation rarely depends on clinical urgency alone.

I am particularly interested in the role of familiarity and therapeutic relationships. Knowing a patient appears to provide more than additional information. In the example of a patient with COPD, the GP can ask whether the current illness feels as severe as a previous admission and judge how much weight to place on that response. The meaning of what is said in the present encounter is therefore shaped by a history of previous encounters.

This can be understood through the phenomenological account offered by Benner and Wrubel ², who emphasise that people make sense of present situations through their past experience. What a patient says now is not interpreted in isolation: previous encounters provide a background against which the present situation is understood. Continuity therefore does more than increase how much a GP knows about a patient; it can change how presently available information is interpreted. A similar process appears in interprofessional relationships, where familiarity with colleagues shapes the weight given to their clinical judgements.

Such relational knowledge is not infallible: familiarity and previous experience can also introduce bias. Learning to use these relational resources well therefore requires opportunities to examine how experience is shaping judgement. McClarey and colleagues rightly highlight the need to teach prioritisation explicitly. Tactical decision games can make otherwise tacit reasoning discussable, while some relational resources for judgement develop longitudinally. A trainer–trainee relationship that supports reflection over time may help clinicians recognise when accumulated experience is enriching their understanding of a situation and when it may instead be introducing bias.

References

1. McClarey A, Dunsmore A, McNab D, Smith SE. Exploring GPs’ prioritisation dilemmas—‘quick wins’ versus ‘eating the frog’: a qualitative study in primary care. Br J Gen Pract 2026;76(770):e763-e770. doi:10.3399/BJGP.2025.0628.
2. Benner P, Wrubel J. The primacy of caring: stress and coping in health and illness. Addison-Wesley; 1989.
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Competing Interests: None declared.

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