The use of clinical information in diagnosing chronic heart failure: a comparison between general practitioners, cardiologists, and students.

In a clinical judgement analysis study, 27 general practitioners, 22 cardiologists, and 21 medical students assessed 40 case vignettes with regard to the probability of heart failure, in order to study the weights of different kinds of information (cues) measured by the regression coefficients in a multiple regression model. The vignettes were based on actual patients. We found that diagnostic accomplishment and diagnostic strategies were surprisingly similar on the group level, but very different on the individual level. The most important cues for the participants were cardiac enlargement and pulmonary stasis. Strategies in which cardiac enlargement was the predominating cue led to a higher diagnostic accomplishment; a third of the participants used such strategies. The cues given in the vignettes could have been utilized more efficiently; cardiac enlargement seems to be more important and "classical" symptoms less important for predicting heart failure than the participants realize.

[Decision making--an area of expertise in health care]. / Beslutsfattande--ett kunskapsområde för sjukvården.

Decision making is of great importance in medicine, and can be analysed according to different theories and research traditions, each with its own criteria for what is meant by a good or correct decision. In classic decision analysis, the criterion is rationality, defined as adherence to logic and probability computation. In clinical judgement analysis, the criterion is agreement with the conditions of external (ecological) reality and how well we adapt to them. According to the naturalistic decision making tradition, there is no better criterion than the opinion of experts in the field. This is discussed in the article, and some of the research traditions are presented.

How do GPs use clinical information in their judgements of heart failure? A clinical judgement analysis study.

OBJECTIVE: To study general practitioners' (GP) clinical diagnoses of heart failure. DESIGN: A Clinical Judgement Analysis study. SETTING: Primary health care. SUBJECTS: Twenty-seven GPs from nine health centres in Stockholm County. INTERVENTION: Forty-five case vignettes, based on actual patients from two health centres in Stockholm, were presented to each GP. For each case vignette, the GPs judged the probability of heart failure. MAIN OUTCOME MEASURES: The GPs' assessments of the probability of heart failure in the case vignettes. The GPs' utilization of clinical information in their judgement strategies, as measured by the regression coefficients in a multiple regression equation, with the probability assessments as dependent and the clinical criteria as independent variables. RESULTS: The variation between the GPs' assessments of the probability of heart failure was considerable. The judgemental strategies differed between the doctors, the most important variables for most of them being lung and heart X-rays and a history of myocardial infarction. CONCLUSIONS: With new treatment recommendations, it has become increasingly important to identify patients with heart failure. This study demonstrates large differences in GPs' diagnoses of heart failure. An important source of this variation is the differences in how they make use of clinical information.