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Practice Diagnosis in General Practice

Diagnostic strategies used in primary care

BMJ 2009; 338 doi: (Published 20 April 2009) Cite this as: BMJ 2009;338:b946

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  1. C Heneghan, clinical lecturer 1,
  2. P Glasziou, professor of evidence based medicine 1,
  3. M Thompson, senior clinical scientist 1,
  4. P Rose, university lecturer 1,
  5. J Balla, honorary principal fellow 2,
  6. D Lasserson, clinical lecturer 1,
  7. C Scott, academic general practice registrar 1,
  8. R Perera, university lecturer in medical statistics 1
  1. 1Department of Primary Health Care, University of Oxford, Oxford OX3 7LF
  2. 2Department of Medicine, University of Melbourne, Australia
  1. Correspondence to: C Heneghan carl.heneghan{at}

    The strategies used by general practitioners in making a diagnosis are being formally recognised; this article is the first in a series that will illustrate their application, and is accompanied by a case study (doi:10.1136/bmj.b1187)

    A clinician’s ability to diagnose accurately is central in assessing prognosis and prescribing effective treatments. However, the strategies clinicians use to arrive at a diagnosis, particularly in primary care, make only a small contribution to current research and the medical curriculum.1 Seminal research in the 1970s showed that the commonly taught sequential approach to history taking and examination, resulting in differential diagnosis and ultimately a final diagnosis, is not what practitioners do in reality.2 3 Researchers observed that diagnostic hypotheses are made early in the consultation and guide subsequent history and examination, in a process of hypothetico-deductive reasoning.2 This work sparked debate about our understanding of the complex strategies used in diagnostic reasoning,4 5 but most work has been done away from the clinical setting.

    This series of articles aims to set out the strategies and methods that are used by general practitioners (GPs) in routine clinical consultations. To check that these strategies were actually used in practice, we conducted a pilot of diagnostic consultations from our own practices (box).

    Identifying and refining diagnostic strategies used in general practice

    We conducted two sessions of group discussion and a prospective evaluation of these strategies during primary care consultations.

    In the pilot phase, a focus group composed of GPs and researchers in primary health care identified several possible diagnostic strategies, based on consensus opinion and the published literature. Use of these strategies was assessed in a consecutive series of 100 patients presenting with a new condition to one GP (CH). Strategies were recorded on a spreadsheet at the end of each consultation. The group of GPs then discussed these pilot …

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