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.
Keywords Clinical reasoning, diagnosis, doctor, grade, symptom
Declaration of Interests Dr Bhandari has received honoraria for lectures and funding to attend conferences from Amgen, Roche, Astellas, BMS, Novartis and Pfizer. No external or internal funding was used to carry out this study.
