1. Focusing the Clinical Assessment Knut Schroeder General Practitioner, Bristol Honorary Senior Clinical Lecturer University of Bristol Meeting on CPRs Dublin Friday 4th June 2010

2. 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

3. From ‘full’ to ‘focused’ FullFocused Time ~ 45 mins~ 10 mins AimsDiagnosisPrognosis/holistic Style Emphasis on data collection Integrated and flexible reasoning (multi-level) StructureFixed structure Tailored to the clinical presentation Prevalence of disease High pre-test probability of disease Low pre-test probability of disease

4. Potential of the consultation Sullivan, F. et al. BMJ 2005;331:831-833 Adapted from: Stott NCH, Davies RH. J Roy Coll Gen Pract 1979;29: 201-5 Copyright ©2005 BMJ Publishing Group Ltd.

5. 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)

6. 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

7. Inductive process. Copyright ©2009 BMJ Publishing Group Ltd. Sullivan & Wyatt BMJ 2005

8. Hypothetico-deductive process. Copyright ©2009 BMJ Publishing Group Ltd. Sullivan & Wyatt BMJ 2005

9. Diagnostic stages & strategies. Copyright ©2009 BMJ Publishing Group Ltd. Heneghan, C et al. BMJ 2009;338:b946

10. Strategies used for refining diagnosis Copyright ©2009 BMJ Publishing Group Ltd. Heneghan, C et al. BMJ 2009;338:b946

11. 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

12. 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

13. 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

14. Restricted rule-out: Example 18 year old student with 2 day hx fever Likely diagnosis: VIRAL INFECTION Rule out:  Meningitis  Meningococcal septicaemia  Chest infection

15. Stepwise refinement Anatomical location of a problem  Arm  Leg Pathological process  Bacterial  Viral Heneghan, C et al. BMJ 2009;338:b946

16. Stepwise refinement: Example 55 year old man with leg pain Refinement: Foot 1 st MTP joint Diagnosis: GOUT

17. 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

18. 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

19. 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

20. 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

21. 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)

22. 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)

23. CPRs in the consultation Pneumonia – CRB 65 Sore throat - Centor AF and stroke risk – CHADS 2 Stroke Risk- ABCD 2 Appendicitis - Alvarado

24. Clinical Confidence The three C’s: Caring Communicating Competence (Stone, Am J Med 2006, McCormick BJGP 2000)

25. Clinical Confidence …make this the FOUR Cs: Caring Communicating Competence …and Clinical Prediction Rules