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Est. 2002

CHAT- trainee        CHAT-trainer        CHAT-TPD

Decisions, Diagnoses & Uncertainty

in the GP consultation








If you have files you would like me to host on here and share with others, OR if you would like to help develop these pages further, then please email me.

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)?

Please leave a comment if you have a tip, spot an error, spot something missing or have a suggestion for a web resource. And of course, if you have developed a resource of your own, please email it to me to share with others.

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