Focusing the Clinical

Assessment

Knut SchroederGeneral Practitioner, Bristol

Honorary Senior Clinical LecturerUniversity of Bristol

Meeting on CPRsDublin

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

Style Emphasis on

data collection

Integrated and flexible reasoning

(multi-level)

Structure Fixed structureTailored to the

clinical presentation

Prevalence of disease

High pre-test probability of

disease

Low pre-test probability of

disease

Potential of the consultation

Sullivan, F. et al. BMJ 2005;331:831-833Adapted 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 problemArm Leg

• Pathological processBacterialViral

Heneghan, C et al. BMJ 2009;338:b946

Stepwise refinement: Example

55 year old man with leg pain

Refinement:•Foot

•1st MTP jointDiagnosis:

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 (Borrell-Carrió 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 ConfidenceThe three C’s:

Caring

Communicating

Competence

(Stone, Am J Med 2006, McCormick BJGP 2000)

Clinical Confidence…make this the FOUR Cs:

CaringCommunicating

Competence

…and Clinical Prediction Rules