Clinical reasoning in general practice

Clinical reasoning in general practice

Apr 17, 2019 0
general practice,onthepods

James chats to Dr Charlotte Hespe about clinical reasoning in general practice. Clinical reasoning is an important skill invaluable to all doctors. Ultimately, it determines patient care outcomes. Learn more about what this skill is and how to implement it in this podcast. We’ll also share a couple of example cases with you.

Summary Writer:  Emily Qian

Script Writer:  Elizabeth Campbell

Editor:  Charlotte Hespe

Interviewee:  Charlotte Hespe

About Dr Charlotte Hespe

Dr Charlotte Hespe is a GP Clinician and Practice Owner of a general practice in the inner city of Sydney, where she has worked for the last 20 years. She is a GP Supervisor and the practice is a fully accredited practice. It functions as a teaching practice for both medical students and GP registrars.

Charlotte also works as Associate Professor, Head of General Practice and GP Research for The University of Notre Dame, Australia, School of Medicine, Sydney. She is the current Faculty Chair for NSW/ACT and Vice President, RACGP. She is an immediate past Chair for Central and Eastern Sydney PHN. And she is currently a director on the Board (EIS Health). Charlotte holds a FAICD qualification. And she has extensive experience in corporate Governance with 17 years’ experience as Chair in several Boards with a primary health care focus.

Clinical reasoning in general practice

With Dr. Charlotte Hespe, General Practitioner, Associate Professor and Head of General Care Practice and Primary Care Research Unit for the University of Notre Dame, Sydney, New South Wales, Australia

 

Introduction

Clinical reasoning is an important skill invaluable to all doctors which ultimately determines patient care outcomes. Dr. Charlotte Hespe, an experienced general practitioner, discusses the role of clinical reasoning in the setting of general practice.

The process of procuring and evaluating information gained from both history and examination to develop an understanding of a patient’s presentation. It requires integration of a patient’s presentation within their clinical context to develop both provisional and differential diagnoses which guide focused investigations and management. The process of clinical reasoning relies on both experience and medical knowledge.

  • Type 1 (fast) – Relies on instinctive thinking and initial impressions. May be based on a classical or typical constellation of symptoms and signs which immediately lead the practitioner towards a certain diagnosis
  • Type 2 (slow) – Allows logical evaluation and analyses of fast thinking. It is primarily reflective and involves systematically evaluating differential diagnoses. It also involves reflection on the doctor-patient interaction, allowing both positive and negative aspects of the interaction to be considered
  • General practitioners practice in a less supervised environment and must thus rely on strong clinical reasoning skills
  • General practitioner registrars in particular are in a vulnerable setting which usually relies on greater medical experience and medical knowledge – This may mean there is difficulty knowing when help is required and more mistakes regarding clinical reasoning which are made
  • Consultation sessions are short in comparison to inpatients in a hospital which indicate that common conditions, critical conditions and red flags are imperative to consider
  • First impressions – Watch the patient’s gait as they ambulate into the room
  • History taking – Ask onset of pain, character of pain, mode of injury, temporality, alleviating or aggravating features, functional limitations, systems review (bladder/bowel incontinence, paraesthesias, weakness)
  • Determine what is most concerning for the patient – Often an overlooked question
  • Consider provisional and differential diagnoses – E.g. mechanical back pain (including soft tissue damage), primary bone malignancy, secondary bone metastases
  • Examination – Tailor to information gained on history, e.g. neurological examination if features of bladder/bowel incontinence, lumbar spine examination if mechanical injury suspected
  • Investigation – If provisional were to be mechanical back pain as likely in this scenario, nil further investigations required unless persistent or progressive symptomatology
  • Management for mechanical back pain – Appropriate rest (note that degree of exercise is helpful), consider physiotherapy, simple analgesia, inform on red flag symptoms for re-presentation
  • First impressions – Important to ascertain what is of greatest concern to the patient (e.g. difficulty coping at work, effect on relationships, etc.)
  • History taking – Ask open ended questions, determine temporality, social history (alcohol, drug use, social stressors at current). Note to be aware of biases as the patient may attribute greater importance in one aspect of the history which may detract from the underlying aetiology
  • Consider provisional and differential diagnoses – E.g. pregnancy, implanon-related, depression, anaemia, iron deficiency, dietary insufficiency, thyroid disease, renal disease, mental health illnesses, etc
  • Examination – Vital signs, signs of chronic disease, other focused examination dependent on history (e.g. mineral/vitamin deficiency signs, thyroid examination, features of anaemia)
  • Investigations – Depression assessment, bedside (pregnancy tests, urinalysis), bloods (e.g. iron studies, FBC, EUC, TFTs, B12, folate)
  • Management – Always consider lifestyle plans (diet, exercise) and red flags
  • General practitioners require strong clinical reasoning skills due to their often independent practice of medicine
  • Employing both fast thinking (instinctive) and slow thinking (reflective) is vital in allowing appropriate evaluation of a clinical presentation to help guide differential diagnoses and thus examination, investigation and management
  • All medical doctors require mastering of the art of clinical reasoning in order to make informed decisions during clinical practice and improve patient outcomes

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Tags: #clinical experience,#clinical reasoning,#communication,#diagnosis,#fast thinking,#General Practice,#history and examination,#patient centred care,#slow thinking

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