Sources of uncertainty in making early diagnosis

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It is now well recognized that transferring the care of a patient from one caregiver to another is a vulnerable point in a patient’s care and a potential threat to patient safety. There may be many intra-disciplinary and inter-disciplinary transition points in the ED during an individual patient’s care. The process requires that each participant communicates well with others to establish an accurate shared mental representation of the important issues. To minimize transition failures, the process should be trained and standardized, recognized as a multiprofessional activity, defined by who should be present, where and when it should occur, and have an end-point that is a clear plan for the ongoing care of the patient. The reliabilility, consistency, and efficacy of the transition should be a hallmark of departmental culture. Training should be provided in how the process works and how it fails. The broad distinction between the transfer of poor information (unwarranted opinions, stereotyping, stigmatization, gratuitous comments, overconfidence, and other cognitive biases) and poor transfer of information (unstructured, casual setting, rushed/fatigued, interruptions/distractions, limited input from others, verbal only, degraded narrative skills) should be recognized. It is important to reliably express the amount of certainty attached to what is actually known at transfer so that recipients clearly understand what is expected of them. The vulnerability of human memory should be recognized and strategies used to deal with it (SBAR, I-PASS and others). There should be awareness of particular biases in communication at transition time. Serial position effects describe how primacy (information presented at the beginning) and recency (the last information to be presented) may influence what is perceived and retained. It is important to be aware of specific biases that operate at transition time: framing, fundamental attribution error, search satisficing and others) and consider strategies to mitigate them.

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To the consultation, the patient brings ideas, concerns, expectations, feelings and emotions related to his health problem. These areas are often grouped together and called the “Patent’s Agenda”. Some of these emotional concerns may be explicit “Open Agenda”, but a large part may never be expressed openly if doctors do not proactively elicit them. In 1981, Barsky, an American psychiatrist, gave a name to this assortment of hidden concerns; he called it the “Hidden Agenda”. An important objective of a medical consultation is to understand as much as possible these hidden emotions. Unless the doctor is able to fathom these, the patient may only be left with therapy that will treat his most obvious symptoms but not resolve the underlying problems.

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C H A P T E R 1 Clinical reasoning, evidencebased practice, and symptom analysis Basic health assessment involves the application of the practitioner’s knowledge and skills to identify and distinguish normal from abnormal findings. Basic assessment often moves from a general survey of a body system to specific observations or tests of function. Such an approach to assessment and clinical decision making uses a deductive process of reasoning. For example, a specialist examining a patient with known hyperthyroidism would conduct a physical examination to test for deep tendon reflexes. Brisk or hyperreflexic reflexes would lead the practitioner to conclude that a hyperthyroid state is a likely cause of these findings. This would greatly narrow the choices of diagnostic tests and treatment decisions. Advanced assessment builds on basic health assessment yet is performed more often using an inductive or inferential process, that is, moving from a specific physical finding or patient concern to a more general diagnosis or possible diagnoses based on history, physical findings, and the results of laboratory and diagnostic tests. The practitioner gathers further evidence and analyzes this evidence to arrive at a hypothesis that will lead to a further narrowing of possibilities. This is known as the process of diagnostic reasoning. Diagnostic reasoning Diagnostic reasoning is a scientific process in which the practitioner suspects the cause of a patient’s symptoms and signs based on previous knowledge. The practitioner gathers relevant information, selects necessary tests, makes an accurate diagnosis, and recommends therapy. The difference between an average and an excellent practitioner is the speed and focus used to arrive at the correct conclusion and initiate the best course of evidencebased treatment with minimum harm, cost, inconvenience, and delay. This expertise of the practitioner is acquired through knowledge and a skill set developed through experience in clinical practice. Repeated practice with real cases helps to develop memory schemes for relating clinical problems and store them in longterm memory. By using diagnostic reasoning, the practitioner is able to accomplish the following: • Determines and focuses on what needs to be asked, what data need to be obtained, and what needs to be examined • Performs examinations and diagnostic tests accurately • Clusters all pertinent findings • Analyzes and interprets the findings • Develops a list of likely or differential diagnoses The diagnostic process The primary care context The process of assessment in the primary care setting begins with the patient or caregiver stating a reason for the visit or a chief concern. Most visits to primary care providers involve concerns or symptoms presented by the patient, such as an earache, vomiting, or fatigue. The initial evidence is collected through a patient history. Demographic information, such as gend ...

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