Focusing the Clinical
Assessment
Knut Schroeder
General Practitioner, Bristol
Honorary Senior Clinical Lecturer
University of Bristol
Meeting on CPRs
Dublin
Friday 4th June 2010
Clinical assessment
History and examination provide basis for
safe and effective practice (Sackett 1992)
New doctors - difficulty with transition
from ‘full’ to ‘focused’
General Practice - unselected and
undifferentiated presentations
GP consultation needs to be focused and
patient-centred
From ‘full’ to ‘focused’
Full
Focused
Time
~ 45 mins
~ 10 mins
Aims
Diagnosis
Prognosis/holistic
Emphasis on data
collection
Integrated and
flexible reasoning
(multi-level)
Fixed structure
Tailored to the clinical
presentation
High pre-test
probability of
disease
Low pre-test
probability of disease
Style
Structure
Prevalence
of disease
Potential of the consultation
Sullivan, F. et al. BMJ 2005;331:831-833
Adapted from: Stott NCH, Davies RH. J Roy Coll Gen Pract 1979;29: 201-5
Copyright ©2005 BMJ Publishing Group Ltd.
Consultation length
Many GP appointments 10 minutes or
less
Can be difficult to assess complex
patients in less than 15 mins (Freeman 2002)
Longer consultations identify
psychological problems better (Howie 2002)
Applying focus to the consultation
Systematic data gathering
More effective if acknowledging and
responding to patient’s problems
and concerns (Freeman 2002)
Integrate communication and clinical
skills
Need holistic and patient-centred
approach
Inductive process
.
Copyright ©2009 BMJ Publishing Group Ltd.
Sullivan & Wyatt BMJ 2005
Hypothetico-deductive process
.
Copyright ©2009 BMJ Publishing Group Ltd.
Sullivan & Wyatt BMJ 2005
Diagnostic stages & strategies
.
Copyright ©2009 BMJ Publishing Group Ltd.
Heneghan, C et al. BMJ 2009;338:b946
Strategies used for refining diagnosis
Copyright ©2009 BMJ Publishing Group Ltd.
Heneghan, C et al. BMJ 2009;338:b946
Pattern recognition fit
Symptoms and signs are
compared with previous
patterns or cases
Refinement strategy most
commonly used by GPs
Relies on memory of known
patterns
Pattern recognition fit: Example
65 year old woman
with tiredness:
•Doesn’t like the cold
•Constipated
•Lack of energy
•Weight gain
•Coarse skin
•‘Hair problems’
Diagnosis:
HYPOTHYROIDISM
Restricted rule-outs
• Also called ‘Murtagh’s process’
• Start with most common cause –
“probability diagnosis”
• Rule out a shortlist of serious
diagnoses Heneghan, C et al. BMJ 2009;338:b946
Restricted rule-out: Example
18 year old student
with 2 day hx fever
Likely diagnosis:
VIRAL INFECTION
Rule out:
 Meningitis
 Meningococcal
septicaemia
 Chest infection
Stepwise refinement
• Anatomical location of a
problem
Arm
Leg
• Pathological process
Bacterial
Viral
Heneghan, C et al. BMJ 2009;338:b946
Stepwise refinement: Example
55 year old man
with leg pain
Refinement:
•Foot
•1st MTP joint
Diagnosis: GOUT
Probabilistic reasoning
Specific but imperfect use of
symptoms, signs, diagnostic
tests
Rule in or rule out diagnosis
Heneghan, C et al. BMJ 2009;338:b946
Probabilistic reasoning: Example
40 year old woman
with SOB
•Leg swelling and pain
•Hip operation 3/52
ago
•Tachycardia
•Positive d-dimer test
Diagnosis:
Pulmonary embolism
Clinical prediction rule
• Formal version of pattern recognition
and probabilistic reasoning
• Based on validated research
• Additional value of symptoms and signs
• Work out probabilities
• Diagnosis & prognosis
• Ruling in and ruling out diagnosis
CPR Example: Wells Score (PE)
40 year old woman with SOB
Wells score:
 Suspected DVT - 3 points
 Alternative diagnosis is less
likely than PE - 3 points
 Tachycardia - 1.5 points
 Immobilization/surgery in
previous four weeks - 1.5 points
 Hx of DVT or PE - 1.5 points
 Haemoptysis - 1 point
 Malignancy (treatment for
within 6 months, palliative) - 1
point
Role of CPRs in avoiding errors
• Errors more likely due to clinical
reasoning rather than lack of
knowledge or incompetence (Scott 2009)
• Need to cultivate self-awareness (BorrellCarrió 2004)
• Common error is wrongly estimating
pre-test probability (Fahey 2008)
• Good communication skills are
important (Panting 2004)
Integrating IT & CPRs
• Using computers is part of ‘modern’ GP
consultation
• Diagnostic guidelines
• Decision aids
• Improve clinical performance (Montgomery 1998)
• May change flow of consultation (Silverman 2007)
• GPs appropriately reduce use of computers in
psychological problems (Chan 2007)
CPRs in the consultation
Pneumonia – CRB 65
Sore throat - Centor
AF and stroke risk – CHADS 2
Stroke Risk - ABCD2
Appendicitis - Alvarado
Clinical Confidence
The three C’s:
Caring
Communicating
Competence
(Stone, Am J Med 2006, McCormick BJGP 2000)
Clinical Confidence
…make this the FOUR Cs:
Caring
Communicating
Competence
…and Clinical Prediction Rules