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Decisions, Diagnoses & Uncertainty

in the GP consultation

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path: MAKING DECISIONS

path: UNCERTAINTY

path: MEDICAL WISDOM (PHRONESIS)

A thorough history & know your RED FLAGS

Okay, there’s no way getting around this – but you need to do a good clinical history taking full stop.   That doesn’t mean you are going to fail if you forget to ask one ot two things out of 15 (unless those two things were crucial like asking about suicide in depression).

For example, I see a lot of trainees who do a depression history by asking about mood, and then social anhedonia, and then concentration.  And that’s it.  They think they are done!  But what about irritability, sexual anhedonia, not eating, initial insomnia, interrupted sleep and early morning wakening?   You cannot just do a little bit!  You have to cover most of it.

Red Flags

And then that brings us onto the red flags.  There’s absolutely no way around that – you have got to know your stuff.    That is why I created the “Red Flags for the CSA” document in the DOWNLOADS section above.   Think about it for a moment – red flags are all about making sure that nothing terribly serious is going on.  So wouldn’t you agree that the doctor who doesn’t check for serious things going on in a comprehensive and structured manner should fail?

Dr Giam explains this more.  Watch the video on the right.  

Do a FOCUSED examination

You will not be required to do a ‘general’ examination in the CSA exam – it’s too much to do.  Instead, you will be asked to do a focused examination – and the examination you will do is the examination YOU THINK you need to do having heard all the history.

Please don’t examine lots of systems just to cover your back and hedge your bets.  Choose the most appropriate system because they are testing you to see whether you have the DECISION-MAKING SKILLS required to choose an appropriate examination.

And remember to SIGNPOST to the patient when you’re doing an examination and why.

Only do tests that are necessary

Again, remember that the CSA examiners are trying to work out if you have good DECISION-MAKING SKILLS in terms of determining which tests need doing.    

Some trainees again hedge their bets and cover there backs by ordering all tests under the sun – but that is bad.  Bad because the NHS is not full of money, and we should be responsible the way we spend it.  All these tests cost lots of money.  Why don’t you ask your local lab how much a particular test costs just to shock yourself. 

But not only that.  Surely, we should be using our brains and our clinical knowledge to guide is what is needed and what is not.  

So, yes, someone with Tiredness All The TIME (TATT) going on for 3 months may well need a whole load of blood tests – FBC, U&E, LFTs, TFTs, HBA1C, and ESR.   But what about the patient who has had TATT for 1-2 weeks?  Do they really need any of these?   Isn’t the history a bit too short and a wait and watch policy more useful?

The art of making diagnoses and decisions

In this section, I want to talk about Type 1 and Type 2 THINKING which is sometimes referred to as FAST and SLOW thinking.  Knowing this stuff will REVOLUTIONISE the way you think and make decisions.  Understanding this will help you practice SAFE medicine (and stop you from being sued through clinical mistakes).

Watch the video on the right where Dr Daniel Kahneman (the amazing guy who discovered all of this and got a Nobel Prize for it) explains it really well.  

Fast Thinking (System 1)

This system helps with the quick decisions you make and these can be life-saving.  For example, if I say man in middle of street crushing at chest and then falls to floor.  You think MI and you rush over and try to save him.  

Another example – rash in a dermatome on the side of a chest – you think at a glance, shingles.  One more – child very unwell, floppy, has non-blanching rash = meningitis.  In other words, you don’t have to think too hard about it.     

Slow Thinking (System 2)

The slow system slows your thinking down and in so doing makes you make a rational and well-considered decisions.   For example, a lady presents to you with chest pains – and there are bits that make you worry (e.g. going down the left arm,) but other bits that are not so worrying (sharp/burning in character).   At first you don’t know whether to refer or not. When you slow down – you think and think and think until eventually you rationally decide that because she is 67, you’re not going to take the chance and so you refer her.

Understanding the two systems...

FAST THINKING sounds like an amazing system doesn’t it – because it saves the patient, makes you feel proud and it saves your butt!   But FAST THINKING can sometimes let you down by making you make rash decisions and therefore bad clinical management plans.   

For example, a lady who rings you and wants a home visit for a cough, and before you’ve spoken, you think… “I’m not going to do that.  No way”.  That’s your FAST system working on your own cognitive illusion of “a cough = minor illness = no big deal”.   And actually, the research shows that you will subconsciously then try and gather SELECTIVE data that fits in with this quick conclusion that you have made – “Oh, so you’ve managed to eat okay today”, “and you’re out of bed” “Oh well that’s good”.     But if we SLOWED down and use our SLOW system, that would encourage us to ask more questions.   And if we did this, we might get the following story.   

  • Pt: “Yeah, normally I wouldn’t call you about the cough“. 
  • Dr: “What’s worried you Mrs X?” 
  • Pt: “Well I’ve manage to get out of bed but then I collapsed.  And although I am up, I feel dreadful and sometimes getting confused.  My partner never stays with me when I’m ill but this time she has because she’s worried too”. 

Now – doesn’t that seem like it warrants a face-to-face consultation?   Do you see how SLOW thinking has saved the day and has stopped the FAST THINKING from making a big mistake? 

Don’t get me wrong.  FAST THINKING is not bad – it can be life-saving.  But the key to being a good GP and making good decisions is being aware of these two systems when you are making decisions and to reflect on which system is at play on a given occasion and whether it is appropriate or not.  Because once you decide you’re using a system that is not the optimal one, that then gives you the AWARENESS to change to the other one.  This ability to flex between these two styles (style flexibility) is what makes a good GP with good decision-making skills.  And you end up living a more wory-free GP life.  Doesn’t that sound great (or do I make things sound too good)?

PS Have you ever met anyone who you didn’t at first like (FAST SYSTEM 1) but later on at some point you think actually this person is okay and I quite like them (SLOW SYSTEM 2)?

Clinical Decision-Making - red, amber and green

Those of you who have been my GP trainees, will often hear me talk about red, amber and green patients.  Red patients are those that are worrying – like those that have features of meningitis.   Green patients are those that are not too worrying – like those who simply have a viral URTI.   And amber patients are those inbetween – i.e. those that you not quite sure of.  An  amber patient is not quite worrying as a red patient but also not as reassuring as a green patient.  

Those that are red patients are easy to manage – you usually admit them.   For example, a meningitis case, you would give benzylpenicillin (or equivalent if allergic) and admit them straight to hospital.   Can you see – whilst the condition is worrying, the decision-making involved is easy – you know what to do.   Those that are green patients are also easy to manage and again the decision-making is easy.   A simple viral URTI = watchful waiting with appropriate safety-netting.   But it is in the amber patients where decision-making becomes more difficult.   They are not as clear-cut as red and green patients.  These are require more complex decision making.   

Let’s explore this clinical decision-making in a bit more detail.

  1. First of all think which light the patient is currently at – red, amber or green?
  2. Then determine, according to their history so far, whether they have changed colours.

Scenarios:

  • RELATIVELY STRAIGHT-FORWARD CLINICAL-DECISION MAKING
        • Patient initially started as green and remains green
          The decision-making, although it varies on the clinical presentation, is relatively easy.   For example, symptoms of a viral URTI which have become a bit worse but you still think viral URTI = watchful waiting + appropriate safety netting.  Or someone with back pain as a result of going on an activity trip – with no alarm features – you may suggest analgesia and exercises.  
        • Patient started green and is now red
          This is a lot more worrying.  You will most probably want to admit.  Using the example above – the patient who initially had what sounds like a viral URTI but now is very ill and on examination you think they may have a LRTI.   They look so unwell that you feel they need an admission,  for IV antibiotics.
        • Patient was amber but now red
          This is the patient who you were a bit worried about but upon review is actually worse.  So, take the possible LRTI who you gave antibiotics to, but then comes back a few days later and looks dreadful.  Clearly, they need admitting. 
        • Patient presents as red
          These always need admitting.  The patient who has had three fits today but no history of epilepsy or anything else.     Or the patient with meningitis features – you give benzylpen (or equivalent) and admit.   The patient who comes in a floppy drowsy worrying state.  You get the idea?
  • MORE COMPLEX CLINICAL-DECISION MAKING
        • Patient started green and is now amber
          This is a bit more worrying.   You either want to start treatment and review.   For example, the patient who initially had what sounds like a viral URTI but now is more ill and on examination you think they may have a LRTI.   If they don’t look to bad for admission,  you might start antibiotics and review them in a few days (with appropriate safety-netting should things suddenly turn).


          Dr Edward Snelson (Paediatrician) writes:
          A 2 year old child presents with a cough, runny nose and a fever.  When you see them they are miserable but alert and interactive.  They have a temperature of 39.5, heart rate of 160 and are refusing to drink.  They last had any symptomatic treatment 6 hours ago.  The parent reports (you have to ask about this – it won’t usually be volunteered) that 2 hrs ago they looked much better and were drinking a bit.  Unlike actual traffic lights, unwell children swing from green to amber and back to green quite normally during uncomplicated self-limiting infections.  There is a reason that we mostly see unwell children between the age of 6 months and six years.  It’s not because they are high risk for dangerous infections.  In fact quite the opposite – it is a stage of life characterised by extreme response to simple infections.  The normal physiological response can look bad but usually resolves to reveal a reassuring baseline.  In many ways, a febrile unwell 2 week old is easier from a decision making point of view – that is a very high risk presentation.  A febrile unwell 2 year old is low risk but that presents a different problem – how to recognise the small number that do have a serious illness. What can be terribly inconvenient is the above situation.  The snapshot we are given is not green but also not red.  Red is also easier from a decision making point of view.  Amber presentations make us have to decide what to do next.  Here are your options:

              • Unwell children will often present with an amber feature which is felt to be related to a lack of symptomatic treatment rather than a sign of serious illness.  If that is the case you have the following options…
                    • Send the child home with symptomatic treatment advice and safety netting advice
                    • Send the child home with symptomatic treatment advice and arrange remote or face-to-face review later
              • Refer the child to paediatrics
        • Patient was amber and remains amber
          This is a very difficult one.   You will want to either keep a close eye on the patient (through doing a few more tests, different treatment and a review in a few days time) or admit them.  For example, the LRTI that doesn’t seem to be settling despite 3 lots of antibiotics.   You might consider an urgent CT or even 2ww if there are other worrying features.
        • Patient was amber but now green
          Generally, you can relax a bit more – the patient seems to have gone through a bad patch and is now settling.  For example, those patients who sound like they were quite unwell (and should have seen), but have put off coming to the doctor and actually come in only when their symptoms seem prolonged although a lot better now.  So, take the patient who did not present to the doctor earlier, but sounded quite poorly with their chestiness (wasn’t eating or drinking much, found it slightly difficult to breathe, had rigors and chills) but presents to you in the second week because the cough hasn’t gone although they are feeling lots better and their breathing back to normal.   So, while you can relax a bit because they seem to be improving, always safety-net because the patient can turn again from their current green status to amber or red at short notice!   And this applies especially to infants and children – their colour situation can change suddenly even if they present to you as green.


          Dr Edward Snelson (Paediatrician) writes:
          Consider this scenario: A 2-year-old child presents with a cough, runny nose, and a fever.  The parent reports that a couple of hours ago they looked pale and lethargic.  They were shivering, and felt hot centrally but had cold hands and feet.  Now they have none of those things happening.  They are walking, talking and cheerfully interactive.  This is a very common scenario.  Parents and carers will often express a certain paradoxical frustration with the apparent wellness of the child.  The child appeared seriously unwell a couple of hours ago and the parent is now feeling that you will think that they have overreacted.


          What you can do
          :

          1. It is a good thing to acknowledge how unwell the child was and use that as an opportunity to..
          2. Explain why you as a clinician are happy with the child despite how concerning the child’s appearance was.  
          3. Safety-net in case the child turns again.   (Consider giving or signposting to something written)
          4. What you can say: “What you told me about how unwell (child’s name) was earlier sounds quite frightening. It is still very reassuring that they look better now. At this age children respond to infections quite strongly and that can cause some things that can look really concerning.  The temperatures can go very high and that immune response causes all of the things that you saw. It’s actually really good timing that they were at their best when I saw them because it allowed me to be able to be confident that it wasn’t signs of something like sepsis or meningitis. Children with sepsis and meningitis don’t do the things your child is doing now. I’m happy for you to continue managing your child’s illness with medicine that make them feel better such as paracetamol and ibuprofen.”

From this, you should be able to see that in terms of CLINICAL DECISION-MAKING, 

  • Green patients are easy
  • Red patients are relatively easy
  • Amber patients is where the decision-making complexity lies and requires more careful thought.
 

Clinical Decision-Making - top tips

 
  • The decision about which strategy to use is influenced by many factors including
        • Confidence in the patient/parent/carer ability to seek appropriate reassessment
        • Whether you feel it is necessary to have the opportunity to document an improvement in physiological parameters (usually heart rate, BP, O2, temp)
        • whether you feel that the patient needs another clinician to assess
  • REVIEWS: Every clinician will have a preferred option.  Many working in Primary Care do not feel the need to have a face to face reassessment if the patient improves in behaviour and activity.  That is completely valid as such improvement is a good demonstration of physiological change and evidence that the baseline state of the patient (active, interactive, good oral intake and no increased work of breathing) is not consistent with sepsis or meningitis for example.
  • Really good safety-netting advice empowers the patient/parent to make that assessment in a way that is dynamic and continuous.  A reassessment in whatever form (face to face or remote) facilitates documentation of improvement and adds value to the safety-netting advice by giving the opportunity for the parent to further discuss the illness, what to expect and when to worry.  We can equip the person caring for that child with the ability to recognise signs of serious illness should those develop later. 
  • Amber patients are a fair bit of work but they are a great opportunity to do what we should consider core business.  We can take a group of patients who are reasonably low risk and look for signs (e.g. increased work of breathing, meningism or unexplained tachycardia) that this one is the one with something that needs immediate intervention.  For those that are within what is expected of an uncomplicated infection we can make sure that they have symptomatic treatment in the assumption that they will demonstrate a baseline state of reasonable wellness that effectively rules out serious illness. 
  • REMEMBER, INFANTS & CHILDREN CHANGE QUICKLY!   Paeds is a dangerous specialty because infants and children can be fine one moment and deteriorate rapidly the next (and vice versa!).   Therefore, always safety-net: i.e. provide the care-giver (e.g. the parent) information/knowledge of the types of things to look out for and what to do if they occur.  Make sure these instructions are clear and explicit.  Write them down if needs be, especially if the information is heavy. 
  • Common outcomes are common but beware of AVAILABILITY BIAS.  But do not let common things being common cloud your judgement in terms of not looking for other things.   Yes, most kids with a cough will have a viral infection and recover nicely.  BUT you are there to assess how they have been and how they are rather than rely on this outcome liklihood alone.
  • SAFETY-NET CAREFULLY: Consider patient expectations and concerns and aim to give safety net advice to reassure them and guide them as to when they need to seek further review.
  • SEEK ANOTHER OPINION IF UNSURE: If you are unsure what is going on and whether a patient needs admission for observation always speak to your colleaguesfor advice. 
  • Trust your instinct!

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How IT ALL STARTED
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Bradford VTS was created by Dr. Ramesh Mehay, a Programme Director for Bradford GP Training Scheme back in 2001. Over the years, it has seen many permutations.  At the time, there were very few resources for GP trainees and their trainers so Bradford decided to create one FOR EVERYONE. 

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4th February 2024 

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