Clinical Decision Making
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2-2.30
2.30-2.45
2.45-3.25
3.25-3.45
3.45-4.25
4.25-5pm
Hot topic
House keeping
Presentation
Coffee
Case histories
Plenary
House keeping
• ST1 induction next Thursday at the MAC
– others meet at BMI as usual.
– cluster work on clinical areas with presentations
• Ophthalmology 1st October
– questions to Malcolm please
• IMG conference 5th November
– details on the website
• Residential 12th-13th November Stourport Manor Hotel
– £79.00 bed & breakfast and £89.00 for double occupancy
– You need to book yourselves and say it is for South B’ham VTS
• Feedback on last 2 weeks
Clinical Decision Making in
General Practice
Patient’s presenting
complaint
History,
examination +/further tests
Diagnosis
Treatment
The King's Fund:The Quality of GP
Diagnosis and Referral 2010
The role of the GP in diagnosis :
problem recognition and decision-making.
A crucial aim of the GP in this regard is to marginalise
danger by recognising and responding to signs and
symptoms of possible serious illness.
The objective is not always to reach a
definitive conclusion…
The King's Fund: The Quality of GP
Diagnosis and Referral 2010
A definition of diagnosis:
A provisional
formula designed
for action
Quoted in "Diagnosis -The Achilles Heel?"
JGR Howie JRCGP 1972
The diagnostic label
• A working diagnosis on which treatment is based (such as
“acute otitis media”)
• A working diagnosis on which further investigations are
planned (such as “bloody diarrhoea ? inflammatory bowel
disease”)
• A working diagnosis indicating the absence of serious disease
(such as “calf pain, not DVT”).
Abdominal pain
Endometriosis
Non specific
abdominal pain
Renal colic
Chronic pelvic pain
Constipation
Irritable
bowel
syndrome
Dyspepsia
Epigastric pain
Dysmenorrhoea
Acute
cholecystitis
Two errors in diagnostic labelling
• Not making a diagnosis eg wheeze vs asthma
• Prematurely making a diagnosis eg asthma vs wheeze
What we say matters
• Randomised trial of positive attitude
• Positive consultation with prescription
– Firm diagnosis, told it WILL get better
• Positive consultation with out prescription
• Negative consultation with prescription
– “I cannot be certain…” “not sure if treatment will work”
• Negative consultation without prescription
– “I cannot be certain…therefore I will give no treatment”
• 200 patients, URTIs, pains in arm/head/chest/back etc
19/9/2003
What we say matters
Positive
consultation
(better/total)
Negative
consultation
(better/total)
Prescription given
32/50
21/50
No prescription
32/50
18/50
TOTAL
64/100
39/100
NNT = 4
19/9/2003
Challenges in diagnosis in GP
• the evolutionary and undifferentiated nature of symptoms
encountered in primary care
• very low prevalence of certain conditions and the high degree
of overlap in symptoms for serious and common conditions
• the difficulty of probability-based reasoning and the weak
predictive value of diagnostic tests in primary care
• the high prevalence of medically unexplained symptoms that
lack a medically identifiable organic cause.
The King's Fund: The Quality of GP
Diagnosis and Referral 2010
High quality diagnostic process
• gathering sufficient evidence and information
• judging that evidence and information correctly
• minimising delay in further investigation and onward
management – particularly if the condition is serious
or suspected to be serious
• ensuring efficient use of resources
• providing a good patient experience.
The King's Fund: The Quality of GP
Diagnosis and Referral 2010
Consultation Aims: Pendleton et al
1. Define the reason for attendance.
2. Consider other problems.
3. Choose an appropriate action.
4. Achieve a shared understanding.
5. Involve the patient in management.
6. Use time and resources appropriately.
7. Establish or maintain a relationship.
Some interesting stats re diagnosis…
• Correct diagnosis is missed or delayed in between 5% and
14% of acute hospital admissions.
• Autopsy studies confirm diagnostic error rates of 10-20%
• 1/3rd adverse events involved errors of execution (slips,
lapses, or oversights in carrying out decisions)
• ½ adverse effects involved errors of reasoning or decision
quality (failure to elicit, synthesise, decide, or act on clinical
information)
• Reasoning errors led to death or permanent disability in at
least 25% of cases, and at least three quarters were deemed
highly preventable.
and management…..
• Even if the diagnosis is correct, up to 45% of
patients with acute or chronic medical
conditions do not receive recommended
evidence based care
• Between 20% and 30% of administered
investigations and drugs are potentially
unnecessary
Who are these doctors?
• no more than 10% of clinicians admit, when asked,
to any error in diagnosis over the past year,
• Clinicians often stay wedded to an incorrect
diagnosis, even if the correct one is suggested by
colleagues or by decision support tools
• Being an older and presumably more experienced
clinician also does not guarantee better quality care
or lower risk of reasoning error
• Most errors in clinical reasoning are not due to
incompetence or inadequate knowledge but
to frailty of human thinking under conditions
of complexity, uncertainty, and pressure of
time.
Ian Scott ; BMJ 339:22-25
• Misdiagnosis caused by hurried consideration of symptoms
and failure to extract key information from patients causes a
great deal more expense and patient suffering than getting
things right first time.
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‘We have to be wise in the way we spend money. If physicians
are paid to talk and listen to patients, and are given the
training to learn how to extract the key information, it is
probably going to be much more cost-effective to do that
properly than rush through consultations and send patients
off for a series of tests.
Edward Davie BMA
Analysis of 631 negligence claims
against GPs related to diagnosis by
condition
Stages and strategies in arriving at a diagnosis
Glasziou, P. et al. BMJ 2009;338:b1312
Copyright ©2009 BMJ Publishing Group Ltd.
It is 4 30 pm, and your last patient of the day is a 42 year old
woman in excellent health who awoke with pain located in the
right infrascapular region that worsens with deep inspiration.
She reports no dyspnea, cough, fever, or recent prolonged
immobilization.
Her vital signs and physical examination are normal.
Your initial impression is that some type of musculoskeletal
condition is causing her pain. Then you begin to wonder. Could
this be a pulmonary embolus? Your gut says “no,” but your brain
continues to dwell on this possibility.
Predicting Pulmonary Embolus in Primary
Care. BMJ 8th Sept 2015
Predicting Pulmonary Embolus in Primary
Care. BMJ 8th Sept 2015
NICE pathway PE 2015
Heuristic techniques
mental shortcuts that ease the cognitive load of making a decision
Sources of error in GPs’ clinical
diagnostic reasoning
• Cognitive oversight— simply not thinking of the correct diagnosis,eg
forgetting coeliac disease as a cause of iron deficiency anaemia
• Failure to gather adequate data— eg inadequate physical
examination for lower bowel symptoms caused by colorectal cancer
• Misinterpretation of data— eg diagnosing gout on the basis of a
raised serum urate concentration or excluding it on the basis of normal serum
urate.
• Anchoring— sticking to an initial diagnosis despite disconfirming evidence,
such as treating fatigue as depression despite evidence of abnormal renal function
• Inappropriate confirmation— selective use of evidence to confirm
an incorrect diagnosis, such as attributing importance to minor abnormalities in
laboratory tests as an explanation for fatigue in someone with depression
• Premature closure — arriving at a conclusive diagnosis before
collecting all the data, such as diagnosing intermittent (vascular) claudication in a
patient with lumbar canal spinal stenosis, jumping to conclusions
Where no diagnostic label is applied. R
Jones BMJ 25 May 2010
Decision-making: errors in estimate of
probability
• Availability – what springs to mind might be rare but memorable or something you’ve
recently experienced
• Representativeness – over estimating the likelihood of a condition because it fits a
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classical description of a condition ( a prototype) or the inverse.
Probability transformations - when according to prospect theory small probabilities
are overweighted and large probabilities are underweighted)
Support theory - effect of description detail more detailed case description given higher
probability)
Order of presentation of information later presented info weighted more than
earlier presented info
Effect of benefits of detection probably linked to perceived costs of mistakes. Regret
bias
Hassle bias – making a diagnosis that will cause the least work
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• Commission bias – feeling the need to do something
A man with a sore leg
Case Histories
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Introduction to case with some questions
Role play history
STOP
Examination findings if needed
Decision making
Discuss possible errors in decision making for
your case and how might you avoid them
Case 1
Chest pain
NICE. Chest pain of recent onset. last
modified March 2010
Chest pain of recent onset NICE
• Unless clinical suspicion is raised based on other aspects of
the history and risk factors, exclude a diagnosis of stable
angina if the pain is non-anginal (see recommendation
1.3.3.1).
• Other features which make a diagnosis of stable angina
unlikely are when the chest pain is:
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continuous or very prolonged and/or
unrelated to activity and/or
brought on by breathing in and/or
associated with symptoms such as dizziness, palpitations, tingling
or difficulty swallowing.
• Consider causes of chest pain other than angina (such as
gastrointestinal or musculoskeletal pain).
NICE last modified March 2010
Case 2
Lower abdominal symptoms
NICE…
…recommends that if a woman has the following symptoms and they last for a
month or more, or occur on at least 12 days in a month, she should see her GP
to be checked for ovarian cancer:
Feeling bloated (having a swollen tummy).
Feeling full quickly and/or loss of appetite.
Pain or discomfort in the lower tummy area and/or back.
Needing to pass urine more often or more urgently (feeling like she can’t
hold on).
NICE also says that if a woman over 50 develops symptoms similar to irritable
bowel syndrome (IBS), such as bloating and changes in bowel habit, she
should be offered tests by her GP to check for ovarian cancer. This is because
it’s unusual for a woman of this age to develop IBS if she hasn’t had it before.
Case 3
cough
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for
lung cancer if they:
have chest X-ray findings that suggest lung cancer or
are aged 40 and over with unexplained haemoptysis. [new 2015]
1.1.2 Offer an urgent chest X-ray (to be performed within 2 weeks) to assess for lung cancer in
people aged 40 and over if they have 2 or more of the following unexplained symptoms, or if they
have ever smoked and have 1 or more of the following unexplained symptoms:
Cough
Fatigue
shortness of breath
chest pain
weight loss
appetite loss. [new 2015]
1.1.3 Consider an urgent chest X-ray (to be performed within 2 weeks) to assess for lung cancer in
people aged 40 and over with any of the following:
persistent or recurrent chest infection
finger clubbing
supraclavicular lymphadenopathy orpersistent cervical lymphadenopathy
chest signs consistent with lung cancer
thrombocytosis. [new 2015]
NICE Suspected cancer recognition 2015
Case 4
dizziness
Hallpike test
Case 5
tiredness
The problem with GP…
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Limited time
Less acute/severe illness
Anxious patients
Reassurance role
Ways to improve decision making in
diagnosis