The Role of Physicians’ First Impressions in the Diagnosis of Possible Cancers without Alarm Symptoms

Kostopoulou, Olga; Sirota, Miroslav; Round, Thomas; Samaranayaka, Shyamalee; Delaney, Brendan

doi:10.1177/0272989x16644563

Cited by 44 publications

(65 citation statements)

References 43 publications

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“…Therefore, while we contend the results are interpretable and reliable, they are not as definitive as a randomised controlled trial result; so, this finding has to be treated with some caution. However, the finding accords with the recent ‘think aloud’ study by Kostopoulou et al ,34 which suggests that when physicians have an idea of cancer early in the consultation, they ask pertinent questions and initiate appropriate investigations to ensure a cancer diagnosis is reached. Therefore, it still seems likely that routinely questioning patients with ongoing respiratory symptoms about weight loss would expedite the diagnosis of some lung cancers.…”

Section: Discussionsupporting

confidence: 80%

Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes

Sheringham¹,

Sequeira²,

Myles

et al. 2016

BMJ Qual Saf

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IntroductionLung cancer survival is low and comparatively poor in the UK. Patients with symptoms suggestive of lung cancer commonly consult primary care, but it is unclear how general practitioners (GPs) distinguish which patients require further investigation. This study examined how patients' clinical and sociodemographic characteristics influence GPs' decisions to initiate lung cancer investigations.MethodsA factorial experiment was conducted among a national sample of 227 English GPs using vignettes presented as simulated consultations. A multimedia-interactive website simulated key features of consultations using actors (‘patients’). GP participants made management decisions online for six ‘patients’, whose sociodemographic characteristics systematically varied across three levels of cancer risk. In low-risk vignettes, investigation (ie, chest X-ray ordered, computerised tomography scan or respiratory consultant referral) was not indicated; in medium-risk vignettes, investigation could be appropriate; in high-risk vignettes, investigation was definitely indicated. Each ‘patient’ had two lung cancer-related symptoms: one volunteered and another elicited if GPs asked. Variations in investigation likelihood were examined using multilevel logistic regression.ResultsGPs decided to investigate lung cancer in 74% (1000/1348) of vignettes. Investigation likelihood did not increase with cancer risk. Investigations were more likely when GPs requested information on symptoms that ‘patients’ had but did not volunteer (adjusted OR (AOR)=3.18; 95% CI 2.27 to 4.70). However, GPs omitted to seek this information in 42% (570/1348) of cases. GPs were less likely to investigate older than younger ‘patients’ (AOR=0.52; 95% CI 0.39 to 0.7) and black ‘patients’ than white (AOR=0.68; 95% CI 0.48 to 0.95).ConclusionsGPs were not more likely to investigate ‘patients’ with high-risk than low-risk cancer symptoms. Furthermore, they did not investigate everyone with the same symptoms equally. Insufficient data gathering could be responsible for missed opportunities in diagnosis.

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Section: Discussionsupporting

confidence: 80%

Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes

Sheringham¹,

Sequeira²,

Myles

et al. 2016

BMJ Qual Saf

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“…Our results depicted how GPs are dependent on patients' stories but also frustrated when these were long and winding, which sheds light on the underlying challenges of the encounter. Adding to the complexity, previous research finds that patients' initial presentation have a predictive value itself [34], and that it is possible to reduce cancer diagnostic delays by asking cancer related questions during the initial phase of the encounter [35]. These findings, in combination with ours, illuminate the complexity of assigning meanings to patients' symptoms, and highlights the importance of the initial phase of the encounter.…”

Section: Discussionsupporting

confidence: 61%

GPs’ perspectives of the patient encounter – in the context of standardized cancer patient pathways

Hultstrand

Coe

Lilja

et al. 2020

Scandinavian Journal of Primary Health Care

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Objective: We aim to explore how GPs assign meanings and act upon patients' symptoms in primary care encounters in the context of standardized cancer patient pathways (CPPs). Design, setting and subjects: Thirteen individual interviews were conducted with GPs, at primary healthcare centers (n ¼ 4) in one county in northern Sweden. Interviews were analyzed using grounded theory method. The results were then linked to symbolic interactionism. Main outcome measures: GPs' perspectives about assigning meanings to patients' presented symptoms and perception about CPPs. Results: In the encounter, GPs engaged in two simultaneous interactions, one with patients' symptomsand the other with CPPs. The core category Disentangling patients' care trajectory consists of three categories, interpreted as GPs' strategies developed to assign meaning to symptoms. These strategies are carried out not in a straightforward manner but rather in a conflicting way, illuminating the complexity of GPs' daily work. Conclusions: Interacting with patients is vital for assigning meaning to presented symptoms. However, nowadays GPs are not only required to interact with patients, they are also required to interact with CPPs. These standardized routines might create pressure and demands on GPs, especially for those experiencing a lack of information about CPPs. Beside of carrying out the challenging patient/person-centered dialogues and interpreting presented symptoms, GPs also need to link the interpreted symptoms to CPPs. Therefore, it is essential that GPs are given opportunities at their workplaces to continuously be informed and be supported in order to practice CPPs and thereby optimize trajectories for patients undergoing cancer diagnostics. KEY POINTS Current awareness:GPs deliberation about patients' trajectories is a complex process, often dealing with vague symptoms. How CPPs influence this process within the encounter has not been studied. Main statements: GPs in our study were involved in two simultaneous interactions, one with patients' symptoms in the encounterand the other with CPPs within the healthcare organization. Symbolic interactionism helped capture how GPs deliberated about conflicting and paradoxical aspects of the encounter, in terms of balancing two contradictory ways of action that GPs face when providing patient/person-centered care and linking to CPPs. Based on our results, primary care needs support from healthcare organizations to build capacity about CPPs and how to use them. ARTICLE HISTORY

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“…First, ID can make an early leader ‘sticky’ by generating unjustified support for it. A strong association between physicians’ first diagnostic impressions and subsequent diagnoses and decisions exists . Thus an incorrect diagnosis may persist simply because it emerged as an early leader.…”

Section: Implications For Health Professionalsmentioning

confidence: 99%

“…A strong association between physicians' first diagnostic impressions and subsequent diagnoses and decisions exists. 47 Thus an incorrect diagnosis may persist simply because it emerged as an early leader. Recall that in the study of UK physicians, 27 decision makers in some cases received an equivalent amount of information supporting a competing diagnosis after seeing neutral attributes.…”

Section: Implications For Health Professionalsmentioning

confidence: 99%

The information distortion bias: implications for medical decisions

Boyle

Purdon

2019

Medical Education

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Context Every diagnosis involves an act of decision making, which requires proper evaluation of information. However, even seemingly objective information can require interpretation, often without our conscious awareness. In this cross‐cutting edge article we describe the phenomenon of leader‐driven information distortion (ID) and its implications for medical education. Information distortion Recent research indicates that one threat to good decisions is a biased interpretation of information to favour one alternative course of action over another. Once an alternative emerges as a leader during a decision there is a strong tendency to evaluate subsequent information as supporting that option. This can occur when deciding between two competing diagnoses. It is particularly a concern if diagnostic tests provide potentially ambiguous results. This leader‐driven ID is pre‐decisional in nature, in that it develops during a decision and involves the interpretation of information available prior to the final decision or diagnosis, with different interpretations possible depending on whichever alternative is the leader. Studies reveal that the distortion bias is pervasive in decisions, and that awareness of the act of distortion is low in decision makers. Application to medical education Empirical research has confirmed the presence of leader‐driven ID in hypothetical diagnoses made by physicians. ID creates two threats to medical decisions: First, it can make a diagnosis sticky in that it is resistant to being overturned by contradictory information. Second, it can promote unwarranted certainty in a diagnosis. The outcome may be premature closure, unnecessary testing or incorrect treatment, resulting in delayed or missed diagnoses. Methods This paper summarises research related to leader‐driven ID in medical and professional decisions and discusses various approaches directed towards reducing ID. A framework and language are provided for thinking about and discussing ID in medical decisions and medical education. Courses of action for mitigating the effects of ID are suggested.

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The Role of Physicians’ First Impressions in the Diagnosis of Possible Cancers without Alarm Symptoms

Cited by 44 publications

References 43 publications

Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes

Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes

GPs’ perspectives of the patient encounter – in the context of standardized cancer patient pathways

The information distortion bias: implications for medical decisions

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