1. Clinical Decision Making
Hot topic
House keeping
Presentation
Coffee
Case histories
4.25-5pm Plenary

2. 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

3. Clinical Decision Making in General Practice

6. Patient’s presenting complaint
History, examination +/- further tests
Diagnosis
Treatment

7. The King's Fund:The Quality of GP Diagnosis and Referral 2010

8. 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

9. A definition of diagnosis:
A provisional formula designed for action
Quoted in "Diagnosis -The Achilles Heel?" JGR Howie JRCGP 1972

10. 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”).

11. Abdominal pain Endometriosis Non specific abdominal pain Renal colic
Chronic pelvic pain
Constipation
Irritable bowel syndrome
Epigastric pain
Note the range from diagnoses from symptom labels to specific pathology representing the range of uncertainty in ‘diagnosing’
Dysmenorrhoea
Acute cholecystitis
Dyspepsia

12. Two errors in diagnostic labelling
Not making a diagnosis eg wheeze vs asthma
Prematurely making a diagnosis eg asthma vs wheeze

13. 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

14. What we say matters Positive consultation (better/total)
Negative consultation
Prescription given
32/50
21/50
No prescription
18/50
TOTAL
64/100
39/100
NNT = 4
19/9/2003

15. 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

16. 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

17. 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.
Our role in decision making is varied but 2 key aspects of consulting are making a diagnosis and negotiating a management plan.
Going to think about making a diagnosis today. May come back to negotiating a management plan on a future occasion.

18. 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.

19. 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

20. 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

21. 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

22. 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.
‘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

23. Analysis of 631 negligence claims against GPs related to diagnosis by condition

24. Stages and strategies in arriving at a diagnosis
Glasziou, P. et al. BMJ 2009;338:b1312
Copyright ©2009 BMJ Publishing Group Ltd.

25. Predicting Pulmonary Embolus in Primary Care. BMJ 8th Sept 2015
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

26. Predicting Pulmonary Embolus in Primary Care. BMJ 8th Sept 2015

27. NICE pathway PE 2015

28. Heuristic techniques
mental shortcuts that ease the cognitive load of making a decision

29. 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
Cognitive oversight—simply not thinking of the correct diagnosis14—for example, forgetting coeliac disease as a cause of iron deficiency anaemia
Failure to gather adequate data—for example, inadequate physical examination for lower bowel symptoms caused by colorectal cancer
Misinterpretation of data—for example, 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,15 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,16 such as diagnosing intermittent (vascular) claudication in a patient with lumbar canal spinal stenosis
Where no diagnostic label is applied. R Jones BMJ 25 May 2010

30. 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 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
Commission bias – feeling the need to do something

31. Too much information in the talk but also the point that often we are confronted with too much information in a consultation

32. A man with a sore leg
52 yr old Polish man 3/12 pan in back and right leg – back of leg and into foot. SLR normal, absent right ankle reflex, normal power.
MRI non-diagnostic
Had vascular disease.

33. Case Histories 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

35. Case 1
Chest pain

36. NICE. Chest pain of recent onset. last modified March 2010

37. 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 ).
Other features which make a diagnosis of stable angina unlikely are when the chest pain is:
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

38. Lower abdominal symptoms
Case 2
Lower abdominal symptoms

39. 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.

42. Case 3
cough

43. NICE Suspected cancer recognition 2015
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

44. Case 4
dizziness

45. Hallpike test

47. Case 5
tiredness

51. The problem with GP… Limited time Less acute/severe illness
Anxious patients
Reassurance role

52. Ways to improve decision making in diagnosis
Listen to the patient
Re-view the diagnosis – when patients keep coming back ask – “am I on the right track, is there something I’ve missed?”
Discuss with colleagues – don’t be afraid of seeming stupid or having a small mind!