How experienced community neurologists make diagnoses during clinical encounters
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Abstract
Study of diagnostic practice is necessary to optimize neurologists' clinical performance and ensure patient safety. To our knowledge, this report is the first set of systematic observations of diagnostic practices of community neurologists in their clinics. The study consisted of six 2-week periods of in situ observations and interviews of 6 experienced community neurologists in Northern California. We describe 3 core domains of diagnosis: 1) clinical (C), 2) laboratory and electrodiagnostics (L), and 3) neuroimaging (N). Neurologists were uniform in their practices across these domains except within the clinical domain, where the physical examination varied considerably among clinicians. All neurologists coordinated findings from the 3 domains to arrive at a final diagnosis. This practice of coordination varied across common disease categories (e.g., meningitis vs dementia). To codify this variance, we developed a provisional model of diagnostic practice derived from the data consisting of a 3-point coordinate shorthand (Cx Lx Nx) and a graphic. This model shows the relative emphasis of each of the 3 core domains for 9 common diagnoses (e.g., stroke is C4 L1 N4 with “4” as the highest priority per domain). The data reveal a heavy emphasis on the clinical domain for most diagnoses. The model may be useful for trainees to learn how to allocate time to make a diagnosis. It may help educators build curricula and evaluation systems that emphasize concrete activities of diagnostic practice. Lastly, our model provides a structure to teach resource utilization and cost containment relating to neurologic diagnoses.
GLOSSARY
- C=
- clinical;
- L=
- laboratory and electrodiagnostics;
- N=
- neuroimaging;
- UCSF=
- University of California, San Francisco
Footnotes
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Supplemental data at www.neurology.org
- Received January 5, 2013.
- Accepted in final form June 13, 2013.
- © 2013 American Academy of Neurology
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Disputes & Debates: Rapid online correspondence
- Response to "Neurology remains a clinical discipline"
- Amar Dhand, Assistant Professor, Department of Neurologydhanda@neuro.wustl.edu
- Amar Dhand, St. Louis, MO; John Engstrom, San Francisco, CA; Gurpreet Dhaliwal, San Francisco, CA
Submitted November 22, 2013 - Neurology remains a clinical discipline
- Nitin K. Sethi, Assistant Professor of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center 525 East 68th Street, New York, NY 1006sethinitinmd@hotmail.com
Submitted November 05, 2013
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