Role of clinician factors in the diagnosis of possible cancer
Factors
Decision-making
Outcomes
Cancer-related
Gut-feeling
PPV 35%; increasing with professional experience & patient age (Donker et al.)
Diagnostic delay/error
Commonly associated themes associated with delayed referral across cancer sites related to the initial diagnosis and activity of the practitioner (Macleod et al.) SysRev: Risk factors for delayed presentation...
Misdiagnosis through Rx patients symptomatically, relating sx to a health problem other than cancer resulted in increased time to referral for breast, colorectal, gynaecological, upper GI and urological cancers
Has added value as a dx tool in addition to sx (Donker et al.)
Correlation between cancer suspicion & more referrals, especially for imaging investigations (Hjertholm P et al. 2014) Predictive value of GPs suspicion of serious disease...
Cancer/serious disease suspicion increased the risk of having a test performed or being referred for further investigation
Action should be taken when GPs suspect serious disease, & the health care system should support this investigation by providing access to imaging and endoscopies
Use of inappropriate or inadequate tests contributes to dx delay
No GP characteristics were associated with doctor delay; but only measured a limited number of factors such as job satisfaction, burnout, seniority) - didn't include factors such as knowledge, attitudes...(Hansen et al) General Practitioner characteristics and delay in...
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MDM's make use of Bayes Theorem, LR, PPVs & decision trees to arrive at the best diagnostic decisions (Stolper et al.); Gut feelings as a third track...
Constitute standard for best practice. Assumption is that these models help physicians avoid cognitive biases and mistakes that arise by relying on own knowledge base
Emphasis is that intuitive hunches may be false and therefore advocates the use of analytical models and decision aids, as well as the monitoring of intuitive ideas by checking for biases before deciding
Intuitive hunches don't always lead to faulty decisions and the use of analytical methods does not always guarantee objective outcomes
Signs/symptoms
Only 1 in 8 patients present with alarm symptoms on first consultation(Ingebrigsten et al.) Frequency of warning signs of cancer in Norwegian general practice...
GPs often use analytical cognitive processes to become aware of cancer such as assessing alarm symptoms (Donker et al; Johansen et al. 2013)
Shows the difficulty and redundancy of diagnosing cancer based on analytical processes such as signs and symptoms alone; meaning that GPs often use other strategies to adjudicate the significance of the patient history
Early/first impressions
can influence DM via biased information search and processing (Kostopolou et al.)
When cancer was acknowledged explicitly at the start of the consultations in 'patients' with non-alarm symptoms, it led to more cancer-related questions
Strong association between first diagnostic impressions and subsequent diagnosis and decisions; bidirectionally
Guidelines promote evidence based practice and ensure equity of access and contain costs (Jiwa et al). Referring patients to specialists: a structured vignette survey...
PPV 9.8% for later dx of cancer or serious disease within 2-months of index consultation and 16.4% within 6-months
Prescribing Rx for benign conditions in patients with upper GI and testicular cancer contribute to dx delay
Other
Cognitive factors (Graber et al); Diagnostic error in internal medicine & Zwaan et al
Faulty synthesis
Premature closure; mistakes were not due to insufficiency of factual knowledge, but to deficiencies in dx approach and judgement
Misjudging the salience of findings
Multi-factorial in origin; often interplay of system and cognitive-related factors, and one error can lead to another (Graber et al)
Future interventions
To identify/target support for the diagnostic processes that are most vulnerable to breakdown (Singh et al) Types & origins of dx error in primary care
Cognitive bias/heuristics
Usually associated with fast & mostly correct diagnoses, it can lead to faulty data-gathering, -synthesis, and dx errors (Zwaan et al. 2013)
Most pre-disposed to dx error during non-specific/atypical presentations, co-morbidity (Kostopolou et al)
New onset alarm symptoms associated with increased likelihood of cancer diagnosis
Alarm symptoms or “red flags” are often used to identify patients whose symptoms need investigation
Referral from primary to secondary care is often triggered by a general practitioner's awareness of so called “alarm symptoms,” features in the clinical presentation that are considered to predict serious, often malignant, disease. For example, guidelines on the identification of alarm symptoms form the core of the “two week rule” for urgent referral of patients suspected of having cancer and many clinical practice guidelines specify particular symptoms that mandate urgent investigation or referral
General practitioners often use individual approaches to the collection and analysis of data in the course of consultations often relying on personal heuristics (Jones);Alarm symptoms in early diagnosis of cancer in primary care
In general practice, incident cancer patients often present with few and non-cancer specific symptoms. The fact that only half of the patients presented with alarm symptoms complicates the GPs' diagnostic work-up and the use of fast track for suspected cancer. Therefore, there is a need for alternative referral pathways for cancer patients with non-cancer specific symptoms (nielson et al); symptom presentation in cancer patients