scispace - formally typeset
Search or ask a question
Journal ArticleDOI

Inductive foraging: improving the diagnostic yield of primary care consultations.

27 Feb 2014-European Journal of General Practice (Eur J Gen Pract)-Vol. 20, Iss: 1, pp 69-73
TL;DR: It is suggested that ‘inductive foraging’ is a relevant and appropriate mode of data acquisition for the first part of the patient encounter, and inductive foraging is a rational and efficient diagnostic strategy.
Abstract: Background: Physicians attempting to make a diagnosis arrive at specific hypotheses early in their encounter with patients. Further data are collected in the light of these early hypotheses. While this hypothetico-deductive model has been accepted as both a description of physicians’ data gathering and a norm, little attention has been paid to the preceding stage of the consultation.Hypothesis: It is suggested that ‘inductive foraging’ is a relevant and appropriate mode of data acquisition for the first part of the patient encounter.Methods: Research evidence from cognitive psychology and medical reasoning research is discussed.Results: With inductive foraging, ‘pattern failure’ rather than ‘pattern recognition’ is the mode of discovery. Largely, guidance should be left to the patient to lead the clinician into areas where departures from normality are to be found. This is in contrast to active and focused ‘deductive inquiry,’ which should be used only after most aetiologies, but a few have elimin...

Summary (2 min read)

1. INTRODUCTION

  • Over recent decades, the development, spread and implementation of internationally accepted quality standards have gained increasing significance.
  • The firm’s quality management system is then verified by a specialized third party, who issues a certificate of conformity when the requirements are met.
  • The authors paper goes beyond this observation and provides the rationale that explains why interest in international standards certification has been growing in developing countries.
  • Second, building on the literature concerning the impact of standards on the performance of firms, this study empirically tests the effects of certificate adoption on the productivity and growth of individual firms, using a wide set of countries, differing in the degree of their economic, social and institutional development.
  • Section seven provides an elucidation of their findings and conclusions.

2. THE NET BENEFITS OF INTERNATIONAL STANDARDS CERTIFICATION (ISC)

  • International management standards currently address a variety of issues including quality management, environmental management, social accountability and working conditions.
  • Quality management reflects what the organization does to enhance customer satisfaction by meeting buyer requirements and expectations (ISO 2002).
  • In 1996, addressing the need for a global system of environmental selfregulation, the environmental management system standard, ISO 14000, was introduced (Delmas, 2002).
  • This view is strongly embedded in the New Institutional Economics perspective, which builds on the influential work of Coase (1937), who identified transaction costs as a factor explaining why some transactions take place within firms and not between firms – and Williamson (1975, 1985) who identified bounded rationality and individual opportunism as factors potentially raising those transaction costs.
  • An efficient competitive market is considered the most powerful force for economic efficiency (Shleifer and Vishny, 1997).

3. HYPOTHESES

  • An significant number of studies have investigated the impact of certification on firm performance.
  • The absence of unequivocal results appears to be associated with variance in the data samples used and heterogeneity of the business contexts in which various companies operate.
  • It is the process of competition and selection in the market that forces firms to respect minimum standards.
  • Firms who intend to sell products to wider markets face more serious information problems since spatial, cultural and linguistic barriers complicate the buyer’s capacity to assess product quality (King, Lenox and Terlaak, 2005, Johnstone and Labonne, 2009, Potoski and Prakash, 2009).
  • Unfortunately, some firms dropped out because information was missing on variables crucial to their analysis, such as employment, capital or sales.

WEGLATEN?

  • The results of the instrumenting equation are in line with expectations.
  • The results in Column (4) also show a substantially different coefficient for the interaction variable combining ISC with the institutional quality of the country.
  • The authors tested the model for ‘trading across borders’, ‘contract enforcement’ and ‘protecting investors’ (Columns (1)-(3)) and extended the analysis by including two components of the Index of Economic Freedom ‘property rights’ and ‘corruption’ (Columns (4)-(5)).
  • The authors find that the extra ISC effect on sales growth of firms in the least developed countries of their sample comes primarily from efficiency improvements.

SALES

  • Age of the firm in t, in logarithmic terms 2.73 (0.75) D-foreign =1 if the firm is foreign owned 0.13 INSTWEAK Institutional weakness measured by the Ease of Doing Business 2008 overall ranking of the country where the firm is active; normalised variable; higher values imply lower institutional quality 0.45 (0.26).
  • Contract Enforcement Institutional weakness measured by the EBD 2008 ranking on the subcomponent ‘Contract enforcement’, of the country where the firm is active; normalised variable, higher values imply lower institutional quality 0.44 (0.25).

Did you find this useful? Give us your feedback

Content maybe subject to copyright    Report

Background Paper
Inductive foraging: Improving the diagnostic yield of
primary care consultations
Norbert Donner-Banzhoff MD, MHSc
1
& Ralph Hertwig PhD
2
1
Department of General Practice, University of Marburg, Germany, and
2
Department of Adaptive Rationality, Max-Planck-Institute for
Human Development, Berlin, Germany
INTRODUCTION
Medical practitioners reasoning and data collection is
often framed as hypothetico-deductive (1). According to
this view, clinicians form a hypothesis based on their fi rst
impression early in the consultation with the patient.
More hypotheses, i.e. possible diagnoses, are added, but
their number is usually limited. Further data collection
by history taking and physical examination is guided
by these early hypotheses. Once the likelihood of a
diagnosis has reached a suffi ciently high threshold, data
collection is stopped, and either treatment is started or
further testing is performed.
Premature closure is said to occur when clinicians
stop their data collection too early and, as a conse-
quence, miss important information. This has been iden-
tifi ed as an important source of diagnostic error (2 4).
In this view, premature closure can happen only after the
rst hypothesis has arisen in the clinician s mind. To date,
little attention has been paid to the period before a
hypothesis has been formed. We would suggest that at
European Journal of General Practice, 2014; 20: 69–73
ISSN 1381-4788 print/ISSN 1751-1402 online © 2014 Informa Healthcare
DOI: 10.3109/13814788.2013.805197
KEY MESSAGE:
· Hypothetico-deductive reasoning has become the orthodox descriptive and normative model. However, this is
not the whole story.
· ‘ Inductive Foraging ’ is a highly effi cient data gathering strategy for generalist practice, when a large number of
aetiologies have to be considered.
· Research from clinical reasoning research, cognitive psychology and education, support the concept of
‘ inductive foraging ’.
ABSTRACT
Background: Physicians attempting to make a diagnosis arrive at specifi c hypotheses early in their encounter with patients. Further
data are collected in the light of these early hypotheses. While this hypothetico-deductive model has been accepted as both a
description of physicians data gathering and a norm, little attention has been paid to the preceding stage of the consultation.
Hypothesis : It is suggested that inductive foraging is a relevant and appropriate mode of data acquisition for the fi rst part of the
patient encounter.
Methods : Research evidence from cognitive psychology and medical reasoning research is discussed.
Results: With inductive foraging, pattern failure rather than pattern recognition is the mode of discovery. Largely, guidance should
be left to the patient to lead the clinician into areas where departures from normality are to be found. This is in contrast to active
and focused deductive inquiry, which should be used only after most aetiologies, but a few have eliminated.
Implication : Especially when the prevalence of serious disease is low, and a wide range of diagnoses must be evaluated, such as in
General Practice, inductive foraging is a rational and effi cient diagnostic strategy. Previously, too little attention has been paid to
the initial stage of the consultation. Premature closure at this point may result in diagnostic error.
Keywords:
decision making , uncertainty , cognition , perception , judgement , diagnosis , general practice , family practice
Conference Presentations : NDB presented parts of this article at the COGITA working group of the European General Practice Research Network, Z ü rich, Switzerland,
October 2010.
Correspondence: Norbert Donner-Banzhoff , Department of General Practice, University of Marburg, Karl-von-Frisch-Str. 4, D-35043 Marburg, Germany. E-mail
norbert@staff .uni-marburg.de
(Received 12 October 2012; accepted 19 April 2013)
Eur J Gen Pract Downloaded from informahealthcare.com by Prof. Dr. med. Erika Baum on 07/11/14
For personal use only.

70 N. Donner-Banzhoff & R. Hertwig
this, the hypothesis-generation phase is of crucial impor-
tance for the diagnostic outcome of the consultation
especially in General Practice.
INDUCTIVE FORAGING
We are suggesting here that a stage to be called induc-
tive foraging precedes hypothesis formation. Ideally,
the space of possible symptoms is searched with an
open mind on the side of the physician. To what degree
clinicians are able to restrain themselves at this stage,
determines the number and appropriateness of diag-
nostic hypotheses considered for an individual patient.
Thus, the foraging stage is an important part of the diag-
nostic process and deserves more attention from clini-
cians, researchers, and educators. We contend that
suffi cient evidence is available to make some tentative
recommendations regarding tactics to be used during
inductive foraging.
During the inductive foraging stage of the consulta-
tion, the patient leads the clinician to areas that are
unusual or worrisome. Here, the predominant diagnostic
strategy may be one of pattern failure rather than pat-
tern recognition (5). Lewis likens the situation to an LCD
monitor screen the working of which one is hardly aware
of. However, if a pixel is not working, one s eye is inevi-
tably drawn to it with the resulting feeling that some-
thing is wrong. Accordingly, in the consultation there is
often a stage when single pieces of information cannot
yet be matched to a pattern. This will stimulate further
probing of unusual phenomena until the range of pos-
sibilities is narrowed into a specifi c hypothesis. Another
possibility is the impression, that something does not
feel right, or that a particular patient is not herself (see
below for meningococcal infection as an example). As
long as no departure from normal is noticed, the default
is the assumption that there is no pathology deserving
further investigation, at least as long the problem space
has been foraged to a suffi cient extent. Inductive forag-
ing has universal application even beyond medical diag-
nosis (6), but it is especially suitable for primary care
where the prevalence of serious disease is low but a
wide range of possibilities must be explored.
EVIDENCE FROM CLINICAL REASONING RESEARCH
Although, our suggestion of inductive foraging is novel
as a diagnostic strategy, there is indirect evidence in the
literature supporting the concept. From his analysis of
Dutch general practitioners (GPs) working with simu-
lated patients, Ridderikhof (7) concluded that inductive
reasoning is the predominant mode of data collection
and reasoning. In his view, information from the patients
serves the process of evoking hypotheses rather than
testing them. Ridderikhof highlighted the speculative
and erratic nature of the hypothesis-generating process,
which he considered at odds with professional account-
ability and the scientifi c foundation of medical practice.
Bordage et al. (8) saw what they call a responsive
mode of enquiry in a more positive light. They encour-
aged clinicians to alternate their thinking between a
deterministic mode, in which questions related to a
specifi c hypothesis are being asked, and a responsive
mode, paying attention to information off ered by the
patient.
The main conclusion drawn from the Medical Inquiry
Project (1) is that a purely inductive method of data gath-
ering is never used by physicians, but that hypotheses
are formed early and guide further work-up. However,
even in this study with standardized patients diagnostic
accuracy was associated with the amount of cues
acquired. In some cases, withholding hypothesis genera-
tion until suffi cient data had been obtained apparently
resulted in better diagnosis. A strategy of inductive
reasoning was associated with diagnostic success in a
think-aloud study of paper cases for medical students
and experienced gastroenterologists (9).
Granier et al. report the retrospective accounts of
Welsh GPs managing children with meningococcal
disease (10). This is an interesting case study since the
condition is so rare that GPs cannot gather suffi cient
experience diagnosing it. Instead, they were using depar-
tures from an assumed normal state as an indication of
a serious problem. The behaviour of parents provided
cues in some cases, such as a mother of three children,
usually coping well, suddenly bursting into tears. Another
point of reference was the image of benign infection.
Children being lethargic, not interacting with either their
parents or the GPs, or crying in an unusual way pre-
sented exceptions to an assumed normality of benign,
self-limiting infection. The matching of information to a
positive pattern was not yet possible at that stage, so
physicians reasoning rather took the form of pattern
failure. This still resulted in optimal decisions, i.e. imme-
diate transfer to hospital. A study of Danish family physi-
cians diagnosing neglect and abuse in children showed
similar results (11). These fi ndings have led to the pos-
tulate that a family of discrepancy heuristics underlies a
large part of diagnostic assessment in primary care prac-
tice (12). Their frame of reference may be previous expe-
rience with a particular patient (within-person
comparison), or typical behaviour of similar patients
(between-person comparison). In some European coun-
tries, GPs are encouraged to act on their gut feelings or
their sense of alarm (13 14).
INSIGHTS FROM COGNITIVE PSYCHOLOGY
Using the background of Popper s theory of falsifi cation
(15) as one benchmark within the context of discovery,
numerous investigators have deplored the seemingly
irrational behaviour of subjects confronted with rule
Eur J Gen Pract Downloaded from informahealthcare.com by Prof. Dr. med. Erika Baum on 07/11/14
For personal use only.

Inductive foraging 71
discovery or diagnostic tasks. Instead of aiming to refute
their hypotheses by searching for disconfi rming evi-
dence, most people seek information that confi rms the
idea (hypothesis) they have formed. Accordingly, clini-
cians seek abnormal symptoms or fi ndings that fi t their
hypotheses. For rational inference, however, one should
evaluate a single piece of information, such as fever,
across hypotheses, and thus draw conclusions from the
absence as well as from the presence of a signal.
Klayman and Ha, however, have suggested that a
confi rmative or positive test strategy can be appropriate,
especially when concrete, task-specifi c information is
lacking, or cognitive demands are high (16). According
to this strategy, individuals search for and examine
instances in which the target behaviour, property, or
event is expected to occur, as opposed to searching for
instances where it is not expected to occur under the
hypothesis entertained. They reason that under certain
circumstances positive evidence is more likely to prove
a hypothesis wrong. This is the case in probabilistic set-
tings and where the target event is rare. The General
Practice consultation is a good example. Here, the prev-
alence of serious disease is low and related pathological
ndings are rare. For each patient, the most likely
hypothesis is thus absence of serious disease. Accord-
ingly, it is the presence of an abnormality that discon-
rms the most likely hypothesis. The presence of an
abnormality is more informative than confi rmation of its
absence. However, the reverse is true if the probability
of the target category, i.e. disease, is high. In that case,
the hypothesis is effi ciently tested also by negative evi-
dence, i.e. absence of fi ndings (16,17).
Human beings fi nd it diffi cult to evaluate isolated
information, especially if presented in a quantitative way.
Often only the provision of an anchor for comparison
enables individuals to evaluate a statement. There is
extensive research showing how anchoring, i.e. compar-
ing a stimulus with a frame of reference, can mislead a
decision-maker if taken to a diff erent context (18 20).
However, despite this line of research, one should not
forget that comparing a particular fi nding with a frame of
reference provides a powerful and ubiquitous heuristic in
human and clinical decision-making. What constitutes
information in the clinical encounter can only be defi ned
by comparison with a reference. Pain experienced by a
patient with chronic rheumatoid arthritis on one of her
good days can be devastating for a person who has not
had musculoskeletal problems before. At this stage,
therefore, it makes sense to leave the initiative to the
patient to lead the physician to problem areas, i.e. areas
where well-being or function diff ers from normal, which
can thus provide clinically relevant information. In this
way, the clinician can make productive use of the frame
of reference defi ned by the patient.
Interestingly, the developers of a computer-based
general medical expert system concluded that one of the
limitations of their product is the inability to take a broad
perspective of a case presented. The system would suff er
from a tunnel vision, and only after having arrived at
specifi c diagnosis would the links to their sophisticated
data base provide satisfactory diagnostic results (21,22).
This example from applied artifi cial intelligence under-
lines the importance of the foraging stage, but also the
diffi culty delegating the task to a machine.
DEDUCTIVE INQUIRY, INDUCTIVE FORAGING AND
PREMATURE CLOSURE
By premature closure, authors usually mean the end of
a phase of specifi c hypotheses evaluation. We suggest
the term deductive inquiry for this phase since reason-
ing goes from propositions (hypothesis) to data gathered
by history taking or examination of the patient. We con-
tend that premature closure can also occur earlier than
that, marking the end of the preceding inductive forag-
ing phase and starting deductive inquiry prematurely
(see Figure 1). This may result in missing relevant diag-
nostic information. Instead, patients should be encour-
aged to elaborate on symptoms or, more generally, on
deviations from their normal state and associated con-
cerns. This strategy promises to yield a rich set of infor-
mation and does not foreclose the retrieval of information
not expected by the clinician. It amounts to a positive
test strategy in so far as the patient can be expected to
focus on noteworthy occurrences of unusual events,
such as symptoms and concerns. In contrast, adopting a
question-and-answer-mode early on risks that the
patient volunteers only the information that has been
explicitly asked for.
There seem to be compelling reasons for physicians
to interrupt their patients early in the consultation
(23,24). To expedite the consultation and thereby save
time is an obvious motive for busy clinicians. A more
subtle consideration refers to re-interpretation of
information in view of a diagnostic hypothesis. Once
Presenting
complaint
asking
questions
answering
questions
1
st
closure
2
nd
closure
Diagnosis
time
PatientClinician
Inductive foraging Deductive
enquiry
2nd
hypothesis
1st
hypothesis
Figure 1. Stages of the clinical encounter and related modes of
inquiry.
Eur J Gen Pract Downloaded from informahealthcare.com by Prof. Dr. med. Erika Baum on 07/11/14
For personal use only.

72 N. Donner-Banzhoff & R. Hertwig
frequent, and often no specifi c cause can be found.
Given enough time, this patient volunteers a history of
pain in the frontal part of her neck and fl u-like symptoms
six months ago for which she had not sought medical
help. These unusual symptoms alert the physician to the
possibility of thyroiditis and consecutive hypothyroid-
ism, which was corroborated later. The graph illustrates
the vast array of pieces of potentially useful information.
Only small areas can be covered with direct active ques-
tioning or searching, as shown in the graph for vital signs,
symptoms of depression and medication that can cause
tiredness. In the example presented here, these are all
negative. However, foraging under guidance of the
patient leads the clinician to a very rare complaint that
triggers specifi c investigations. Premature switching to a
question-and-answer-mode would have resulted in a
longer and less focused process, which would have
delayed defi nite diagnosis considerably.
AREAS FOR FUTURE RESEARCH
Few studies have investigated diagnostic reasoning
and decision making in real practice. Little attention
has been given to the earlier stage of patient-physician
physicians have arrived at their fi rst hypothesis, further
information provided by the patient is seen in a (dis-)
confi rmatory light, i.e. whether or not the information
is relevant to the hypothesis entertained by the practi-
tioner. A large amount of information can be discarded
as not contributing. A messy picture suddenly looks
ordered. However, at this early stage there is a risk of
too greatly reducing the range of possible explanations.
To conclude that relevant diagnoses have been excluded
with acceptable probability, problem areas must be
explored suffi ciently. The order in which this should hap-
pen is best left to the patient. Given enough time, they
will lead the clinician like a sniff er dog on a leash (Anon-
ymous GP, Basle [Switzerland]. Personal Communication.
2009) to areas where information can be found.
CASE STUDY
The effi ciency of inductive foraging as a strategy of data
acquisition is illustrated by the case of a 52-year-old
female patient presenting with tiredness of three
months duration (Figure 2). A vast number of diseases
can cause the symptom. Among these, defi ned somatic
aetiologies are rare. Psychological disorders are more
52 year old woman
with tiredness
Vital signs?
Criteria for depression?
Medication causing
tiredness?
Dry skin
Neck pain and flu-like
illness 6 months ago
PHYSICAL SIGNS
INVESTIGATIONS
Figure 2. Case of a 52 year old woman presenting with tiredness. Graph shows space of potentially relevant information from history, physical signs
and further investigations. ‘ 0 ’ , normal; ‘ 1 ’ , abnormal nding; grey rectangles, information actively asked for routinely.
Eur J Gen Pract Downloaded from informahealthcare.com by Prof. Dr. med. Erika Baum on 07/11/14
For personal use only.

Inductive foraging 73
REFERENCES
Elstein AS , Shulman LS , Sprafka SA . Medical problem-solving: An 1.
analysis of clinical reasoning . Cambridge, MA: Harvard University
Press ; 1978 .
Redelmeier DA . The cognitive psychology of missed diagnoses . 2.
Ann Intern Med. 2005 ; 142 : 115 – 20 .
Graber ML , Franklin N , Gordon R . Diagnostic error in internal 3.
medicine . Arch Intern Med. 2005 ; 165 : 1493 – 9 .
Voytovich AE , Rippey RM , Suff redini A . Premature conclusions in 4.
diagnostic reasoning . J Med Educ. 1985 ; 60 : 302 – 7 .
Lewis DM . Look before you leap . Br Med J. 2009 ; 338 http://www.5.
bmj.com/rapid-response/2011/11/02/look-you-leap (accessed 16
June 2013).
Itti L , Baldi P . Bayesian surprise attracts human attention . Vision 6.
Res. 2009 ; 49 : 1295 – 306 .
Ridderikhoff J . Problem-solving in general-practice . Theor Med. 7.
1993 ; 14 : 343 – 63 .
Bordage G , Grant J , Marsden P . Quantitative assessment of diag-8.
nostic ability . Med Educ. 1990 ; 24 : 413 – 25 .
Coderre S , Mandin H , Harasym PH , Fick GH . Diagnostic reasoning 9.
strategies and diagnostic success . Med Educ. 2003 ; 37 : 695 – 703 .
Granier S , Owen P , Pill R , Jacobson L . Recognising meningococcal 10.
disease in primary care: qualitative study of how general
practitioners process clinical and contextual information . BMJ.
1998 ; 316 : 276 – 9 .
Lykke K , Christensen P , Reventlow S . This is not normal … — Signs 11.
that make the GP question the child’s well-being. Fam Pract.
2008 ; 146 – 53 .
Donner-Banzhoff N . Wie stellt der Allgemeinarzt eine Diagnose? 12.
Z allg Med. 1999 ; 75 : 744 – 9 .
Stolper E , van Royen P , Dinant GJ . The sense of alarm ’ ( ‘ gut feeling ’ ) 13.
in clinical practice. A survey among European general practitioners
on recognition and expression . Eur J Gen Pract. 2010 ; 16 : 72 – 4 .
Stolper E , Van de Wiel M , Van Royen P , Van Bokhoven M , Van der 14.
Weijden T , Dinant GJ . Gut feelings as a third track in general practi-
tioners ’ diagnostic reasoning . J Gen Intern Med. 2011 ; 26 : 197 – 203 .
Popper KR . The logic of scientifi c discovery . London: Routledge ; 15.
2002 .
Klayman J , Ha YW . Confi rmation, disconfi rmation, and informa-16.
tion in hypothesis-testing . Psychol Rev. 1987 ; 94 : 211 – 28 .
Oaksford M , Chater N . Optimal data selection: Revision, review, 17.
and re-evaluation . Psychon Bull Rev. 2003 ; 10 : 289 – 318 .
Slovic P , Finucane ML , Peters E , MacGregor DG . The aff ect heu-18.
ristic . Eur J Oper Res. 2007 ; 177 : 1333 – 52 .
Kahneman D , Miller DT . Norm theory – comparing reality to its 19.
alternatives . Psychol Rev. 1986 ; 93 : 136 – 53 .
Hsee CK , Loewenstein GF , Blount S , Bazerman MH . Preference 20.
reversals between joint and separate evaluations of options: A
review and theoretical analysis . Psychol. Bull. 1999 ; 125 : 576 – 90 .
Miller RA , Pople HE , Myers JD . Internist-I, an experimental com-21.
puter-based diagnostic consultant for general internal medicine .
New Engl J Med. 1982 ; 307 : 468 – 76 .
Spiegelhalter DJ , Knilljones RP . Statistical and knowledge-based 22.
approaches to clinical decision-support systems, with an applica-
tion in gastroenterology . J Roy Stat Soc a Sta. 1984 ; 147 : 35 – 77 .
Marvel MK , Epstein RM , Flowers K , Beckman HB . Soliciting the 23.
patient ’ s agenda — Have we improved? J Am Med Assoc. 1999 ;
281 : 283 – 7 .
Rhoades DR , McFarland KF , Finch WH , Johnson AO . Speaking and 24.
interruptions during primary care offi ce visits . Fam Med.
2001 ; 33 : 528 – 32 .
Howie JG , Porter AM , Heaney DJ , Hopton JL . Long to short con-25.
sultation ratio: A proxy measure of quality of care for general
practice . Br J Gen Pract. 1991 ; 41 : 48 – 54 .
Feufel MA . Bounded rationality in the emergency department . 26.
2009 ; Wright State University, Dayton, Ohio (USA). Unpublished
dissertation.
encounters. By defi nition, this stage is unstructured,
and one cannot easily formulate specifi c rational strat-
egies of inquiry. Moreover, the opening stage of an
encounter depends on the context that cannot be cap-
tured by in vitro studies based on paper cases or stan-
dardized patients. Therefore, future research should
explore the dynamics of the inductive foraging stage
of the consultation, exploratory tactics used by clini-
cians, the responses they elicit from their patients, and
whether these are associated with measures of diag-
nostic success.
CLINICAL AND EDUCATIONAL RECOMMENDATIONS
Health professionals need to be aware of the existence
and value of the inductive foraging stage described
above. They should realize that giving patients suffi cient
time to elaborate on their complaints not only eases the
patients sense of distress (25), but is also likely to
improve the diagnostic outcome of the consultation.
Closed questions referring to the presence or absence of
specifi c symptoms should be reserved for the deductive
enquiry stage. Instead, open questions encouraging fur-
ther exploration and elaboration should be asked, if
needed: How did it start? Have you noticed anything
else? What else is diff erent from usual? What about your
everyday activities? With these kinds of questions clini-
cians will also be able to move the discourse back to
inductive foraging if premature closure has occurred by
the patient. At the same time, clinicians should pay
attention to their sense that perhaps something is not
normal.
The considerations referring to inductive foraging are
particularly relevant for the care of unselected popula-
tions, i.e. primary care or emergency department hospi-
tal settings (26). Here, complaints are often non-specifi c,
and a large number of possible diagnoses must be
screened; inductive foraging may be the most effi cient
way to achieve this. Prematurely advancing to hypothe-
sis-guided deductive inquiry would inappropriately
restrict the scope of possible explanations.
CONCLUSION
Hopefully, the concept of inductive foraging will not
only have a descriptive value, but will also encourage
physicians, teachers and students to refl ect on how their
diagnostic ideas arise. They will fi nd that there is not
necessarily a trade-off between patient-centred commu-
nication and eff ective diagnosis, because skilful induc-
tive foraging can improve both.
Declaration of Interest: The authors report no confl icts
of interest. The authors alone are responsible for the
content and writing of the paper.
Eur J Gen Pract Downloaded from informahealthcare.com by Prof. Dr. med. Erika Baum on 07/11/14
For personal use only.
Citations
More filters
Journal ArticleDOI
TL;DR: In this paper, a narrative review discusses different sources of and reasons for uncertainty and strategies to deal with it in the context of the current literature and concludes that the attitude towards uncertainty correlates with the choice of medical speciality by vocational trainees or medical students.

15 citations

Journal ArticleDOI
TL;DR: How frequently preceptors verified students' history taking and clinical examination skills and how often they gave feedback is analysed to suggest GPs should give feedback more frequently and when doing so, focus on specific feedback.
Abstract: Purpose of the study A general practice and family medicine rotation is mandatory as part of undergraduate medical education. However, little is known about the student-teacher interaction in this specific setting of ambulatory teaching. In this study we analysed how frequently preceptors verified students9 history taking and clinical examination skills and how often they gave feedback. The type of feedback given was also categorised. Methods From April to December 2012, 410 individual patient consultations were observed in 12 teaching practices associated with the Philipps University Marburg, Germany. Material was collected using structured field-note forms and videotaping. Descriptive data analysis was performed. Informed, written consent was provided by all participants. Results We analysed 410 consultations which lasted 14.8 min on average. In 130 (31.7%) consultations students took the patient9s medical history; 124 (95.4%) of these were verified by the general practitioner (GP). Physical examination was performed by students in 202 (49.3%) of consultations; 169 (81.9%) of these were verified by the GP. Feedback occurred in 132 (32.2%) of the 410 patient consultations. Feedback was mostly non-specific and positive (68.9%), and occurred during consultation with the patient present. Specific, negative feedback also occurred relatively frequently (29.5%). Specific, positive and non-specific, negative responses were rarely given. Conclusions GPs should give feedback more frequently and when doing so, focus on specific feedback. GPs should be further instructed in different feedback techniques.

10 citations

Journal ArticleDOI
TL;DR: awareness of the ways patients discuss these relations could help GPs to better understand the patient's view and, in this way, collaboratively move towards constructive explanations and symptom management strategies.
Abstract: Background Primary care guidelines for the management of persistent, often ‘medically unexplained’, physical symptoms encourage GPs to discuss with patients how these symptoms relate to negative emotions. However, many GPs experience difficulties in reaching a shared understanding with patients. Aim To explore how patients with persistent symptoms describe their negative emotions in relation to their physical symptoms in primary care consultations, in order to help GPs recognise the patient’s starting points in such discussions. Design and setting A qualitative analysis of 47 audiorecorded extended primary care consultations with 15 patients with persistent physical symptoms. Method The types of relationships patients described between their physical symptoms and their negative emotions were categorised using content analysis. In a secondary analysis, the study explored whether patients made transitions between the types of relations they described through the course of the consultations. Results All patients talked spontaneously about their negative emotions. Three main categories of relations between these emotions and physical symptoms were identified: separated (negation of a link between the two); connected (symptom and emotion are distinct entities that are connected); and inseparable (symptom and emotion are combined within a single entity). Some patients showed a transition between categories of relations during the intervention. Conclusion Patients describe different types of relations between physical symptoms and negative emotions in consultations. Physical symptoms can be attributed to emotions when patients introduce this link themselves, but this link tends to be denied when introduced by the GP. Awareness of the ways patients discuss these relations could help GPs to better understand the patient’s view and, in this way, collaboratively move towards constructive explanations and symptom management strategies.

9 citations

Journal ArticleDOI
TL;DR: The concurrence between these approaches to knowing is offered here as Transdisciplinary Generalism - a coherent epistemology for both primary care researchers and generalist clinicians to understand, enact, and research their own sophisticated craft of managing diverse forms of knowledge.
Abstract: Transdisciplinary research and generalist practice both face the task of integrating and discerning the value of knowledge across disciplinary and sectoral knowledge cultures. Transdisciplinarity and generalism also both offer philosophical and practical insights into the epistemology, ontology, axiology, and logic of seeing the 'whole'. Although generalism is a skill that can be used in many settings from industry to education, the focus of this paper is the literature of the primary care setting (i.e., general practice or family medicine). Generalist philosophy and practice in the family medicine setting highly values whole person care that uses integrative and interpretive wisdom to include both biomedical and biographical forms of knowledge. Generalist researchers are often caught between reductionist (positivist) biomedical measures and social science (post-positivist) constructivist theories of knowing. Neither of these approaches, even when juxtaposed in mixed-methods research, approximate the complexity of the generalist clinical encounter. A theoretically robust research methodology is needed that acknowledges the complexity of interpreting these ways of knowing in research and clinical practice. A conceptual review of literature to define the alignment between (a) the philosophy and practice of generalism in primary care and (b) both the practical (Zurich) and philosophical or methodological (Nicolescuian) schools of transdisciplinarity. The alignment between generalism and transdisciplinarity included their broad scope, relational process, complex knowledge management, humble attitude to knowing, and real-world outcome focus. The concurrence between these approaches to knowing is offered here as Transdisciplinary Generalism - a coherent epistemology for both primary care researchers and generalist clinicians to understand, enact, and research their own sophisticated craft of managing diverse forms of knowledge.

7 citations

Journal ArticleDOI
TL;DR: The concept of an individual threshold for the utilisation of primary care would explain how GPs use their knowledge of individual patients and their previous help-seeking behaviour for their diagnostic decision making.
Abstract: Background One of the tenets of general practice is that continuity of care has a beneficial effect on patient care. However, little is known about how continuity can have an impact on the diagnostic reasoning of GPs. Aim To explore GPs’ diagnostic strategies by examining GPs’ reflections on their patients’ individual thresholds for seeking medical attention, how they arrive at their estimations, and which conclusions they draw. Design and setting Qualitative study with 12 GPs in urban and rural practices in Germany. Method After each patient consultation GPs were asked to reflect on their diagnostic reasoning for that particular case. Qualitative and quantitative analyses of consultations and interview content were undertaken. Results A total of 295 primary care consultations were recorded, 134 of which contained at least one diagnostic episode. When elaborating on known patients, GPs frequently commented on how ‘early’ or ‘late’ in an illness progression a patient tended to consult. The probability of serious disease was accordingly regarded as high or low. This influenced GPs’ behaviour regarding further investigations or referrals, as well as reassurance and watchful waiting. GPs’ explanations for a patient’s utilisation threshold comprised medical history, the patient’s characteristics, family background, the media, and external circumstances. Conclusion The concept of an individual threshold for the utilisation of primary care would explain how GPs use their knowledge of individual patients and their previous help-seeking behaviour for their diagnostic decision making. Whether the assumption behind this concept is valid, and whether its use improves diagnostic accuracy, remains to be investigated.

7 citations

References
More filters
Book
01 Jan 1934
TL;DR: The Open Society and Its Enemies as discussed by the authors is regarded as one of Popper's most enduring books and contains insights and arguments that demand to be read to this day, as well as many of the ideas in the book.
Abstract: Described by the philosopher A.J. Ayer as a work of 'great originality and power', this book revolutionized contemporary thinking on science and knowledge. Ideas such as the now legendary doctrine of 'falsificationism' electrified the scientific community, influencing even working scientists, as well as post-war philosophy. This astonishing work ranks alongside The Open Society and Its Enemies as one of Popper's most enduring books and contains insights and arguments that demand to be read to this day.

7,904 citations

Journal ArticleDOI

4,047 citations

Journal ArticleDOI
TL;DR: In this article, a theory of norms and normality is presented and applied to some phenomena of emotional responses, social judgment, and conversations about causes, such as emotional response to events that have abnormal causes, the generation of predictions and inferences from observations of behavior and the role of norms in causal questions and answers.
Abstract: A theory of norms and normality is presented and applied to some phenomena of emotional responses, social judgment, and conversations about causes. Norms are assumed to be constructed ad hoc by recruiting specific representations. Category norms are derived by recruiting exemplars. Specific objects or events generate their own norms by retrieval of similar experiences stored in memory or by construction of counterfactual alternatives. The normality of a stimulus is evaluated by comparing it to the norms that it evokes after the fact, rather than to precomputed expectations. Norm theory is applied in analyses of the enhanced emotional response to events that have abnormal causes, of the generation of predictions and inferences from observations of behavior, and of the role of norms in causal questions and answers. This article is concerned with category norms that represent knowledge of concepts and with stimulus norms that govern comparative judgments and designate experiences as surprising. In the tradition of adaptation level theory (Appley, 1971; Helson, 1964), the concept of norm is applied to events that range in complexity from single visual displays to social interactions. We first propose a model of an activation process that produces norms, then explore the role of norms in social cognition. The central idea of the present treatment is that norms are computed after the event rather than in advance. We sketch a supplement to the generally accepted idea that events in the stream of experience are interpreted and evaluated by consulting precomputed schemas and frames of reference. The view developed here is that each stimulus selectively recruits its own alternatives (Garner, 1962, 1970) and is interpreted in a rich context of remembered and constructed representations of what it could have been, might have been, or should have been. Thus, each event brings its own frame of reference into being. We also explore the idea that knowledge of categories (e.g., "encounters with Jim") can be derived on-line by selectively evoking stored representations of discrete episodes and exemplars. The present model assumes that a number of representations can be recruited in parallel, by either a stimulus event or an

2,910 citations

Book ChapterDOI
TL;DR: This article introduced a theoretical framework that describes the importance of affect in guiding judgments and decisions and argued that reliance on such feelings can be characterized as "the affect heuristic" and discussed some of the important practical implications resulting from ways that this heuristic impacts our daily lives.

2,330 citations

Journal ArticleDOI
TL;DR: The authors showed that the positive test strategy can be a very good heuristic for determining the truth or falsity of a hypothesis under realistic conditions, but it can also lead to systematic errors or inefficiencies.
Abstract: Strategies for hypothesis testing in scientific investigation and everyday reasoning have interested both psychologists and philosophers. A number of these scholars stress the importance of disconfir. marion in reasoning and suggest that people are instead prone to a general deleterious "confirmation bias" In particula~ it is suggested that people tend to test those cases that have the best chance of verifying current beliefs rather than those that have the best chance of falsifying them. We show, howeve~ that many phenomena labeled "confirmation bias" are better understood in terms of a general positive test strate~. With this strategy, there is a tendency to test cases that are expected (or known) to have the property of interest rather than those expected (or known) to lack that property. This strategy is not equivalent to confirmation bias in the first sense; we show that the positive test strategy can be a very good heuristic for determining the truth or falsity of a hypothesis under realistic conditions~ It can, howeve~ lead to systematic errors or inefficiencies. The appropriateness of human hypotheses-testing strategies and prescriptions about optimal strategies must he understood in terms of the interaction between the strategy and the task at hand.

1,811 citations

Frequently Asked Questions (14)
Q1. What are the contributions mentioned in the paper "Inductive foraging: improving the diagnostic yield of primary care consultations" ?

In this paper, it is suggested that inductive foraging is a relevant and appropriate mode of data acquisition for the fi rst part of the patient encounter. 

The main conclusion drawn from the Medical Inquiry Project (1) is that a purely inductive method of data gathering is never used by physicians, but that hypotheses are formed early and guide further work-up. 

As long as no departure from ‘ normal ’ is noticed, the default is the assumption that there is no pathology deserving further investigation, at least as long the problem space has been foraged to a suffi cient extent. 

DEDUCTIVE INQUIRY, INDUCTIVE FORAGING AND PREMATURE CLOSUREBy ‘ premature closure, ’ authors usually mean the end of a phase of specifi c hypotheses evaluation. 

Inductive foraging has universal application even beyond medical diagnosis (6), but it is especially suitable for primary care where the prevalence of serious disease is low but a wide range of possibilities must be explored. 

A strategy of inductive reasoning was associated with diagnostic success in a think-aloud study of paper cases for medical students and experienced gastroenterologists (9). 

Keywords: decision making , uncertainty , cognition , perception , judgement , diagnosis , general practice , family practiceConference Presentations : NDB presented parts of this article at the COGITA working group of the European General Practice Research Network, Z ü rich, Switzerland, October 2010. 

From his analysis of Dutch general practitioners (GPs) working with simulated patients, Ridderikhof (7) concluded that inductive reasoning is the predominant mode of data collection and reasoning. 

According to this strategy, individuals search for and examine instances in which the target behaviour, property, or event is expected to occur, as opposed to searching for instances where it is not expected to occur under the hypothesis entertained. 

The authors suggest the term ‘ deductive inquiry ’ for this phase since reasoning goes from propositions (hypothesis) to data gathered by history taking or examination of the patient. 

Using the background of Popper ’ s theory of falsifi cation (15) as one benchmark within the context of discovery, numerous investigators have deplored the seemingly irrational behaviour of subjects confronted with ruleE urJ Gen Pra ctD ownl oade dfr omin form ahea lthca re.c omb yPr of. 

The considerations referring to inductive foraging are particularly relevant for the care of unselected populations, i.e. primary care or emergency department hospital settings (26). 

Premature closure is said to occur when clinicians stop their data collection too early and, as a consequence, miss important information. 

complaints are often non-specifi c, and a large number of possible diagnoses must be screened; inductive foraging may be the most effi cient way to achieve this.