clinical reasoning in general practice dr charles todd
TRANSCRIPT
![Page 1: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/1.jpg)
CLINICAL REASONINGIN GENERAL PRACTICE
Dr Charles Todd
![Page 2: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/2.jpg)
OBJECTIVES
At the end of the session you should:• Understand cognitive methods utilised in
making a diagnosis• Recognise some of the special features that
apply in general practice • Have a strengthened ability to reach an
accurate diagnosis in the general practice consultation
• Understand how and why errors in reasoning occur
![Page 3: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/3.jpg)
KEY MESSAGE:STOP & THINK!
Remember this antismoking slogan? Plus message spray painted over it…
THINK FIRST -
MOST DOCTORS DON’T SMOKE
Smoke first –Most doctors
don’t think!
![Page 4: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/4.jpg)
WHY IMPORTANT?
Diagnostic errors:
i.Common: estimates 10-20%.
ii.Among medical errors are the second leading cause of adverse effects (after medication errors)
iii.Associated with high morbidity.
iv.The most common and most costly source of malpractice payments (in UK & USA).
![Page 5: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/5.jpg)
GENERAL PRACTICE CONSULTATIONS
• Short• Enormously varied• Problems undifferentiated• Serious disease uncommon• Multiple tasks: the key one is to establish
the reasons for the patient’s attendance – with new problems this means reaching a diagnosis
![Page 6: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/6.jpg)
MAKING A DIAGNOSIS
• Key competency for GPs• Forms the basis for determining the patient’s
treatment, prognosis, etc • Concerns moving “backwards” from the patient’s
complaints (the illness) to the disease (target disorder)
• Important to consider physical, social and psychological aspects
• The history is critical – examination and investigations play a relatively small role
![Page 7: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/7.jpg)
KAHNEMAN’S SYSTEMSOF THINKING
• System 1 operates automatically and quickly, with little effort
• System 2 involves effortful mental activity
• While most of the time system 1 is in operation, system 2 can to some extent overrule it
• We can “toggle” between the two
![Page 8: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/8.jpg)
CLINICAL PROBLEM SOLVING IN PRACTICE
What methods are used in reaching a diagnosis?
1) Intuition2) Hypothesis generation and testing3) Follow a structured guideline or
algorithm
![Page 9: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/9.jpg)
INTUITION
• Instant realisation that the presenting signs and symptoms conform to an already known pattern
• Reflex rather than reflective
• Applies where the presentations is very familiar
• “Pattern recognition”
• Kahneman’s System 1
![Page 10: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/10.jpg)
HYPOTHETICO-DEDUCTIVE METHOD
• Analytical approach• Laboured, time-consuming• Kahneman’s System 2• Ideas are generated during the interview about
what the underlying problem is• These “hypotheses” are then tested and
refined by further questions, examination and investigations
![Page 11: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/11.jpg)
MORE ON HYPOTHESES
• Hypotheses are “explanatory ideas” that are increasingly refined through the consultation
• The first are generated very early on in history taking (within seconds)
• Usual strategy followed is to “prove” rather than refute a particular hypothesis
• Used by clinicians of all types – more experienced are better at it
![Page 12: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/12.jpg)
GENERATING HYPOTHESES
Consider:• Probability or likelihood of a given
condition in a specific setting• Potential seriousness and • Treatability
of any possible diagnosis – especially with regard to the value of early detection
![Page 13: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/13.jpg)
WHEN THE GOING GETS TOUGH
• Consider broad categories first, e.g. think about what system is involved
• Keep an open mind
• Look for a unifying diagnosis
• Utilise checklists as aide-memoires
• Avoid fishing expeditions
• Listen to the patient and think!
![Page 14: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/14.jpg)
CHECKLISTSSystem-based Pathological Anatomical
Cardiovascular Congenital Skin
Respiratory Acquired Muscle
Gastrointestinal - Traumatic Bone
Genitourinary - Infective Pleura
Neurological - Inflammatory Lungs
Psychological - Metabolic Heart
etc etc etc
![Page 15: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/15.jpg)
SOURCES OF ERROR AND BIAS• Jumping to conclusions and fixing on them – being “blind” to other
ideas• Basing diagnosis on recall of a similar case from the past or novelty,
rather than awareness of epidemiology in the setting• Continuing reference to existing and/or extension of existing diagnostic
label• Unquestioning faith in diagnostic labels applied by others, especially
consultants• Failure to reassess when things don’t fit with what is expected
• Being distracted by too much information• Focus on ruling in rather than ruling in
![Page 16: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/16.jpg)
ERROR AND BIAS (ctd)• Confirmation bias: focus on ruling in rather than refuting a
particular diagnosis (i.e. only seeking evidence to confirm)
• Over-reliance on results of investigations
• “Colluding” with the patient who is asking for reassurance
• Multiple doctors involved failure to see the bigger picture
• Emotional factors / denial
• Being too tired or rushed
• Lack of knowledge and experience
![Page 17: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/17.jpg)
EXAMPLES FROM PRIMARY CARE SIGNIFICANT EVENTS
Presentation Initial diagnosis Eventual diagnosis Reason for error
60 yr old rectal bleeding
Haemorrhoids Rectal cancer InexperienceFailure to follow guidelines
2 yr old unwell with fever, unusual blanching rash
Viral infection Meningococcal septicaemia
“Blindness” and collusion
40 yr old obese type 2 DM with severe recurrent vertigo
Labyrinthitis Cerebellar stroke Multiple doctorsFailure to reassess
![Page 18: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/18.jpg)
COMMUNICATION SKILLS FOR BETTER DIAGNOSIS
• Listen – and show it• Don’t interrupt (“the golden minute”)• Ask open-ended questions first, then more
directed ones• Be receptive to all verbal and non-verbal
cues• Summarise and check• Be open to the patient’s perspective (ICE)
![Page 19: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/19.jpg)
SPECIAL CONSIDERATIONS IN GENERAL PRACTICE
• Be pragmatic and action oriented
• Use time judiciously
• Don’t trust specialists uncritically
• Learn to live with uncertainty
• Manage risk
• Identify and respond to the patient’s ideas about what is wrong
![Page 20: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/20.jpg)
USE OF CLINICAL EPIDEMIOLOGY TO IMPROVE DIAGNOSTIC
ACCURACY• Statistical methods are underutilised in
reaching a diagnosis
• Estimate initial probability of disease (prevalence in the setting)
• Know specificity and sensitivity of diagnostic tests
• Refine probability based on strength of evidence (“likelihood ratio”)
![Page 21: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/21.jpg)
FINAL TIPS• Generate more than one possible diagnositic idea• Think of the worst thing this could be• Don’t just focus on presenting symptoms: review
recent consultations and look at bigger picture• Always be ready to reconsider or ask a colleague• Listen to your gut, but• Never abandon your critical faculties
![Page 22: CLINICAL REASONING IN GENERAL PRACTICE Dr Charles Todd](https://reader035.vdocument.in/reader035/viewer/2022062313/56649c945503460f94950835/html5/thumbnails/22.jpg)
READINGSackett D, Haynes et al. Clinical Epidemiology. A Basic
Science for Clinical Medicine. Little Brown
Elstein A, Schwarz A. Clinical problem solving and diagnostic decision making... BMJ 2002; 324: 729-732
http://healthland.time.com/2013/04/24/diagnostic-errors-are-more-common-and-harmful-for-patients/
Scott I. Errors in clinical reasoning: causes and remedial strategies. BMJ 2009; 339: 22-25
Fraser R. Clinical Method: a general practice approach. Butterworth Heinemann.
Kahneman D. Thinking, Fast and Slow. Penguin, 2012