1. Analysing GPs' ‘Mental Clusters’ in patients with dizziness U.-M. Schmidt, M. Gulich Department of General Practice, University of Ulm, Germany WONCA Europe, Amsterdam, June 4 th 2004

2. Aim of the study … to identify factors that have an influence on decision making in General Practice: i.e. constituents of the reasoning process WONCA Europe, Amsterdam, June 4 th 2004

3. Methods semi structured interviews with 22 GPs in rural and urban areas including case reports of 117 primary care patients with dizziness or vertigo. Main points of interest were –whether the GP initiated further interventions (examination / investigation / tests / referrals / treatment etc.) –the reasons / influencing factors behind that decision, the “why” or “why not”.. WONCA Europe, Amsterdam, June 4 th 2004

4. Results 1 Examples of well established factors found: –medical knowledge –specific diagnostic ‘if-then-rules’ –diagnosis ex iuvantibus –avoidable potentially dangerous outcome (“abwendbar gefährlicher Verlauf”) –living / experienced history –watchful waiting –… WONCA Europe, Amsterdam, June 4 th 2004

5. Results 2 Several not officially recognized or not fully accepted factors were found, for example: –Avoiding discussions with patient / relatives –Practice economic reasons –Personal opinion/judgement –Number of patients in the waiting room –Personal antipathy –Individual preferences –Previous error –…. WONCA Europe, Amsterdam, June 4 th 2004

6. 80y, female CG1 safety- aspects new symptoms – change of symptoms interactive aspects / emotional dimension: doctor avoids long discussions severe symptoms working with colleagues: delegation of responsibility patient‘s expectations: patient wants diagnostic physical status: Patient old, but fit patient assigned factors symptom assigned factors „not verifyable cerebral mal-circulation“ „doctor-patient- mix“ doctor assigned factors

7. Results 3 medical and non-medical factors form “mental clusters” importance and influence of each of these factors within a cluster differ from case to case there seem to be GP’s personal characteristics within clusters WONCA Europe, Amsterdam, June 4 th 2004

8. We doctors often want to believe: … that our decisions are only based on objective facts and evidence-based knowledge Fact is: … heuristic-based judgement and other often not explicitly accepted factors are also part of the reasoning process Points for Discussion (1) WONCA Europe, Amsterdam, June 4 th 2004

9. (In Germany) there is no structured approach to these aspects of decision making yet Since they are existent, it could make sense to –name and specify these factors –to be aware of their existence and the role they play –to introduce them into medical training (post graduate training) to learn, how to deal with them Points for Discussion (2) WONCA Europe, Amsterdam, June 4 th 2004