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