Abstract
Medical decision-making relies partly on the probability of disease. Current recommendations for the management of common diseases are based increasingly on scores that use arbitrary probability thresholds. To assess decision-making in pharyngitis and appendicitis using a set of clinical vignettes, and the extent to which management is congruent with the true probability of having the disease. We developed twenty-four clinical vignettes with clinical presentations corresponding to specific probabilities of having disease defined by McIsaac (pharyngitis) or Alvarado (appendicitis) scores. Each participant answered four randomly selected web-based vignettes. General practitioners (GP) working in primary care structures in Switzerland and the USA. A comparison between the GP's management decision according to the true probability of having the disease and to the GP's estimated probability, investigating the GP's ability to estimate probability of disease. The mean age of the GPs was 48 years (SD 12) and 66% were men. The correlation between the GP's clinical management decision based on the vignette and the recommendations was stronger for appendicitis than pharyngitis (kw = 0.74, 95% CI 0.70-0.78 vs. kw = 0.66, 95% CI 0.62-0.71). On the other hand, the association between the clinical management decision and the probability of disease estimated by GPs was more congruent with recommendations for pharyngitis than appendicitis (kw = 0.70, 95% CI 0.66-0.73 vs. 0.61, 95% CI 0.56-0.66). Only a minority of GPs correctly estimated the probability of disease (29% for appendicitis and 39% for pharyngitis). Despite the fact that general practitioners often misestimate the probability of disease, their management decisions are usually in line with recommendations. This means that they use other approaches, perhaps more subjective, to make decisions, such as clinical judgment or reasoning that integrate factors other than just the risk of the disease.
Highlights
Medical decision-making relies, at least partly, on the probability of disease, which helps define appropriate thresholds to treat or to do further investigation
The association between the clinical management decision and the probability of disease estimated by General practitioners (GP) was more congruent with recommendations for pharyngitis than appendicitis
Despite the fact that general practitioners often misestimate the probability of disease, their management decisions are usually in line with recommendations
Summary
Medical decision-making relies, at least partly, on the probability of disease, which helps define appropriate thresholds to treat or to do further investigation. According to the likelihood of the disease, three management options usually exist: the diagnosis is excluded, the diagnosis is uncertain and more investigation is needed, or the disease is likely enough to initiate treatment without further investigation. This was described as the “decision threshold model” of disease by Pauker et al in 1980 [1]. With the emergence of evidence-based medicine, clinical epidemiology data reinforces the general practitioner’s (GP’s) experience with the potential to improve clinical practice, which is subjective and sometimes biased [5] The objectives of this clinical prediction rule-centered strategy are to avoid unnecessary investigation (often expensive and sometimes harmful) or overtreatment (leading to antibiotic resistance or side effects) and to minimize misdiagnosis. Current recommendations for the management of common diseases are based increasingly on scores that use arbitrary probability thresholds
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
