Misdiagnosis in primary care covers a wide range of conditions that may be related in the manner in which they present. The challenge is to identify ways of supporting the diagnostic process in potentially difficult presentations.

Distortion could partly explain commitment of physicians to an early diagnosis. Both distortion and strength of initial diagnostic belief seem to decline after 10 years in family medicine.

BackgroundDesigners of computerised diagnostic support systems (CDSSs) expect physicians to notice when they need advice and enter into the CDSS all information that they have gathered about the patient. The poor use of CDSSs and the tendency not to follow advice once a leading diagnosis emerges would question this expectation.AimTo determine whether providing GPs with diagnoses to consider before they start testing hypotheses improves accuracy.Design and settingMixed factorial design, where 297 GPs diagnosed nine patient cases, differing in difficulty, in one of three experimental conditions: control, early support, or late support.MethodData were collected over the internet. After reading some initial information about the patient and the reason for encounter, GPs requested further information for diagnosis and management. Those receiving early support were shown a list of possible diagnoses before gathering further information. In late support, GPs first gave a diagnosis and were then shown which other diagnoses they could still not discount.ResultsEarly support significantly improved diagnostic accuracy over control (odds ratio [OR] 1.31; 95% confidence interval [95%CI] = 1.03 to 1.66, P = 0.027), while late support did not (OR 1.10; 95% CI = 0.88 to 1.37). An absolute improvement of 6% with early support was obtained. There was no significant interaction with case difficulty and no effect of GP experience on accuracy. No differences in information search were detected between experimental conditions.ConclusionReminding GPs of diagnoses to consider before they start testing hypotheses can improve diagnostic accuracy irrespective of case difficulty, without lengthening information search.

BackgroundClinical decision support systems (DSS) aimed at supporting diagnosis are not widely used. This is mainly due to usability issues and lack of integration into clinical work and the electronic health record (EHR). In this study we examined the usability and acceptability of a diagnostic DSS prototype integrated with the EHR and in comparison with the EHR alone.MethodsThirty-four General Practitioners (GPs) consulted with 6 standardised patients (SPs) using only their EHR system (baseline session); on another day, they consulted with 6 different but matched for difficulty SPs, using the EHR with the integrated DSS prototype (DSS session). GPs were interviewed twice (at the end of each session), and completed the Post-Study System Usability Questionnaire at the end of the DSS session. The SPs completed the Consultation Satisfaction Questionnaire after each consultation.ResultsThe majority of GPs (74%) found the DSS useful: it helped them consider more diagnoses and ask more targeted questions. They considered three user interface features to be the most useful: (1) integration with the EHR; (2) suggested diagnoses to consider at the start of the consultation and; (3) the checklist of symptoms and signs in relation to each suggested diagnosis. There were also criticisms: half of the GPs felt that the DSS changed their consultation style, by requiring them to code symptoms and signs while interacting with the patient. SPs sometimes commented that GPs were looking at their computer more than at them; this comment was made more often in the DSS session (15%) than in the baseline session (3%). Nevertheless, SP ratings on the satisfaction questionnaire did not differ between the two sessions.ConclusionsTo use the DSS effectively, GPs would need to adapt their consultation style, so that they code more information during rather than at the end of the consultation. This presents a potential barrier to adoption. Training GPs to use the system in a patient-centred way, as well as improvement of the DSS interface itself, could facilitate coding. To enhance patient acceptability, patients should be informed about the potential of the DSS to improve diagnostic accuracy.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-017-0477-6) contains supplementary material, which is available to authorized users.