Journal Mobile

S Bhandari
Journal Issue: 
Volume 39: Issue 4: 2009




Practising  doctors  are  distinguished  from  other  healthcare  staff  by their  role  in  making  a  clinical  diagnosis.  Huge  changes  in  training  and  working practice in the past 15 years may have left many junior doctors ill equipped or preferring not to synthesise information to conclude a clerking with a diagnosis or differential diagnosis. This report details a retrospective study of acute medical admissions  (AMU)  first  seen  in  the  emergency  department  (A&E)  and  the diagnostic activity of junior doctors in both settings. The documented diagnostic conclusion  and  reported  differential  diagnosis  was  compared  with  that  of  the relevant  admission  consultant. The  aim  was  to  see  if  doctors  completed  their clinical  assessment  by  establishing  a ‘reasonable  differential  diagnosis’  or  simply used the presenting complaint (a symptom) of the patient as the ‘diagnosis’.

One hundred patients’ records (66 male and 34 female of mean age 57.4 years [20–94  years])  were  studied. The  majority  of  cases  came  from  the  cardiac  and neurology domains of diagnosis. A total of 53% of cases seen in A&E by clinicians were  given  a  clinical  ‘symptom’  as  a  final  diagnosis  or  differential  diagnosis. A further 18% referred to the wrong clinical domain in their assessment, and 22% of  cases  were  concordant  with  the  eventual  consultant  diagnosis.  In  the AMU 20%  of  cases  were  given  a  symptom  as  a  final  diagnosis  and  11%  the  wrong domain;  45%  of  diagnoses  were  concordant.  The  grade  of  the  doctor,  from foundation year (FY1) to specialty registrar (ST3), led to an expected improvement in  the  assessment  and  documentation  of  a  possible  diagnosis  rather  than  a symptom  for  both A&E  and AMU  settings.  In  summary,  junior  doctors  did  not routinely document a clinical diagnosis or differential diagnosis at the conclusion of their clerking, regardless of experience. The reasons for this deferred activity are considered.