31
Decision making in general practice
I. R. McWHINNEY, MD
Professor and Chairman, Department of FamilyMedicine, University of Western Ontario, Canada
SUIMMARY. The way in which general practitioners
think during consultations can be analysed. There are
two broad processes: generalizations (placing the
patient's problems in a diagnostic category) and
individualization (assessing the patient and his
behaviour). Ten ways in which clinical decisions taken
in general practice differ from hospital practice are
listed.
Introduction
Training for general practice rests on the premise that the
range of problems seen in general practice is different from
that in other disciplines and that the methods used for
dealing with them are unique to general practice and
cannot be transferred unmodified from other disciplines.
Among these methods, clinical decision making holds a
central place and I wish to summarize the way in which I
Unexpected L evise
cues
F OL
F'GURE 1 MODEL OF PROCESS OF CLINICAL DECISION hlAKING
think the process of decision making in general practice
differs from the process in other medical disciplines.
First, however, I would like to present to you a model
of the process of clinical decision making which applies
to all medical disciplines (Figure 1) and is derived from
the work of Elstein and colleagues (1978).
When the patient presents his problem or problems, the
physician is 'bombarded' with a large amount of
information from many sources: from his own visual
observations, from the patient's story, from the clinical
record, and from the patient's relatives. From all this, the
physician responds to certain cues, a cue being an item of
important information. Often the cues are in the form of a
cluster or pattern.
The physician's response to the cues is to formulate one
or more hypotheses about what is wrong with the patient.
Establishing what is wrong with the patient implies two
Cue(s) |
Hypothesis(es)
I
l
| Decision |
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kinds of judgement: a prediction of the outcome of the
patient's condition and a judgement about its cause or
causes.
Making clinical predictions
Generalization
Two processes are used in making clinical predictions. The
first is a process of generalization. The clinician uses his
general knowledge of the frequency of symptoms and
diseases to place the patient's illness in a category which
we often call the 'diagnosis'. Like all processes of
classification this is a generalization which tends to
ignore individual differences between cases of the same
'disease'.
At the beginning of the process, the clinician can
usually formulate a hypothesis only about the category to
which the illness belongs: the hypothesis must then be
tested and if necessary revised by history, physical
examination, and investigation.
If more than one hypothesis is formed at the same time,
they are put in a ranking order based on two criteria:
1. Probability: the likelihood of the diagnosis, given the
presenting symptoms.
2. Pay-off: the consequences of diagnosing or not
diagnosing the illness. This is based on an assessment
of the disease's seriousness and treatability.
Other things being equal, the most probable hypotheses
will usually be ranked first, but if the pay-off is high for a
particular diagnosis, then this may be ranked high even
though it is less probable. The ranking order of the
hypotheses is important because it is normal to begin the
search by trying to confirm or refute the first-ranking
hypothesis.
Individualization
The second process-individualization-goes on con-
currently with generalization. The prediction based on
generalization is modified by the integration of large
numbers of variables, including the patient's behaviour,
feelings, relationships, and attitudes. The physician's
personal knowledge of the patient obviously plays a large
part in this.
The search
Having formulated his hypothesis(es), the physician
carries out a search to test them. The search strategy has
two main components:
1. The directed search. A strategy which is individually
designed to test the leading hypothesis. This is obviously
different in each case.
2. The routine search. A strategy used by the physician to
uncover unexpected cues by surveying the patient's
functions in a systematic way.
The search is a cyclical process because, as hypotheses
are refuted, new hypotheses are considered and subjected
to testing.
The endpoint of the search
At any one consultation the search ends when the
hypothesis has been refined enough for a management
decision to be taken. Conventionally, this is when a
'diagnosis' is made. Nearly all diagnoses, however, are
statements of probability and the degree of certainty
necessary for a management decision varies greatly from
case to case. The end point of the search depends very
much on its objectives and these vary between clinical
disciplines.
Strictly speaking, it is wrong to speak of an 'end point'
to the search. A management decision is only a temporary
end point, since the patient's progress, or lack of progress,
may still lead to revision of the hypothesis and another
cycle of the search.
How does general practice differ?
By going through the decision-making process I will now
summarize the ways in which decision making in general
practice differs from decision making in other disciplines.
Some have been described elsewhere (McWhinney,
1978).
1. Since the general practitioner sees illness in its early
stages, the cues to which he can respond are both
fewer and different.
2. Since the decision of the patient to consult the
physician is an important aspect of most con-
sultations, the general practitioner has to be
particularly responsive to behavioural cues.
3. Since the probability of encountering diseases in
general practice is different from that in the selected
population of referral specialties, the initial
hypotheses will often be different, or at least be
placed in a different ranking order.
4. Since the general practitioner sees disease in its early
stages, when fewer cues are present, decisions have to
be made at lower levels of probability than in the
later stages ofdisease seen in hospital practice.
5. Since personal knowledge of the patient and his
family is one of the key features of general practice,
individualization plays a relatively more important
part in the formulation of hypotheses.
6. Since the directed part of the search depends on the
initial hypothesis(es), the general practitioner's
search strategy is often different.
7. Since the general practitioner usually has previous
knowledge of the patient, he makes less use of
routine searches.
8. Since the general practitioner's objectives are often
different, the end point of the search may be different.
For example:
(a) In self-limiting illness, the objective may be to
exclude serious disease and the end point may be
reached when this has been achieved. Precise diagnosis
is therefore not required. This has been called
"eliminative diagnosis" by Crombie (1963).
(b) In other illnesses, the objective may be to decide
whether or not referral is required, for example, in
patients with an acute abdomen. The objective may
be achieved when there is enough evidence to make
this decision, even though the precise diagnosis may
not at that point be known.
9. Since in general practice the relationship with
patients is open-ended, there is not the same pressure
to make decisions within a set period of time.
Provided the patient is not at risk the search can be
spread out over several consultations.

10. Since the objectives of the search are different, the
methods used for testing hypotheses may be different.
For example:
(a) The ESR is a most useful test for discriminating
between broad categories like 'active rheumatic
disease/no active rheumatic disease'. It is much less
useful for discriminating between finer diagnostic
categories. The test is therefore of greater use in
general practice.
(b) The continuing relationship with patients in
general practice means that observation of the patient
over time can be used as a very effective test.
Conclusion
I believe this summary includes all the important
differences between the decision-making processes in
general and referral practice. I have arrived at most of
them by reflecting on my own experience and by applying
to it the growing literature on decision making (Crombie,
1963; Braun, 1970; Elstein et al., 1978). I think all
these statements could be regarded as hypotheses which
are eminently testable.
One point interests me particularly. I have thought for
some time that there may be some important differences
in the way general practitioners and referral specialists
think. If there is, then it might explain the communication
33
blocks that are sometimes encountered between them. I
suspect that the crucial difference may lie in the extent to
which generalization and individualization are used in
making predictions. There is some evidence that human
beings show an innate variation in their modes of
thought: some being natural analytical thinkers but poor
integrators, others being good integrators but poor
analytical thinkers.
If we think of this as a scale of attributes, is it possible
that general practitioners, by self-selection and training,
are distributed more at the integrative end of the scale,
while system specialists are found at the analytical end?
Again, this hypothesis is one which could be tested
empirically.
References
Braun, R. N. (1970). Lehrbuch der artzlichen Allgemeinpraxis
(Textbook of Teaching Family Medicine). Miunchen,
Berlin: Urban and Schwarzenberg.
Crombie, D. L. (1963). Diagnostic process. Journal of the
College of General Practitioners, 6, 579-589.
Elstein, A. S., Shulman, L. S. & Sprafka, S. A. (1978).
Medical Problem Solving-An Analysis of Clinical
Reasoning. Cambridge, Massachusetts: Harvard Press.
McWhinney, I. R. (1978). The early diagnosis of undifferen-
tiated problems. In Family Practice. Ed. Rakel, R. E. &
Conn, H. F. 2nd edn. Philadelphia: W. B. Saunders.