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Dr. Alan Brunton, a Specialty Registrar in Acute Internal Medicine and student on the MSc in Evidence-Based Health Care reflects on his experience of our Evidence-Based Diagnosis and Screening module.

Student profile picture, Dr. Alan Brunton

"This module has been the standout unit of the MSc for me so far."

Taking risks

As doctors we have to take risks: it is an awkward truth of the front line of clinical medicine where the cosy idealism of many textbooks meets the harsh uncertainties of healthcare delivered in pressured systems with limited resources.

In order to provide meaningful benefit to our patients, we must face the uncomfortable fact that in trying to improve our patient’s lot we play calculated games of risk each day. It would be easy for this realisation to stun us into paralysis, for fear of making an unforced error and causing harm to those who place their trust in us.

For all the hours of focused study we accumulate, and time on the wards we tally, our experience will always be found wanting given that it can only ever be the sum of the work of one practitioner, which is why courses like the Evidence-Based Diagnosis and Screening module matters.

Embracing uncertainty

To practice medicine in the 21st century requires us to shift from the world of the traditional textbooks - with each condition neatly packaged into tables simplifying it’s causes and management - and onto an evidence-based one where we must embrace uncertainty. It is unlikely that any single diagnostic lead, physical sign, or diagnostic test will provide us with our answers all of the time in every context. Like the clinicians who practice it, the tools of modern medicine are fallible, and when used incorrectly the false certainty this combination can lead to potentially disastrous results in terms of misdiagnosis, over-diagnosis, over-treatment, wasted resources, and poorer patient outcomes.

Over time the skilled practitioner begins to realise that although for every presentation of something as common as chest pain, there may be a legion of potential causes that could be the culprit – for the patient who is actually in front of them, there are perhaps only a few diagnoses it may actually be.

A large part of the role of the diagnostician is working to separate out signal from noise, distilling a sea of possible facts from a patient’s history and examination findings down to a meaningful differential diagnosis and coming up with a sensible and safe management plan. This course  helps us navigate such dilemmas - recognising the challenges faced in this process covering diagnostic strategy and how we can move from possibilistic reasoning (sending all of the possible tests for our patient with chest pain) to probabilistic reasoning with sensible rule-in tests (considering positive likelihood ratios to help us rule in our diagnosis) as well as rule-out tests (considering negative likelihood ratios to exclude serious conditions we do not want to miss). Thoughtful consideration of such specifics help us to become more thoughtful and evidence-based practitioners, and in so doing help us to reduce the burdens of over-diagnosis and over-investigation which alongside screening, are also covered in this course.

It is essential that any modern practitioner strives to become as well versed in the use and limitations of the evidence-base, as they have become with the use of a stethoscope. We cannot hope to achieve the best outcomes for our patients without a rational and balanced approach to diagnosis that recognises the caveats of diagnostic tests and screening programmes. Clearly there is a long way to go for many of us, but courses like this help set-up the thoughtful clinician for a life-time of further learning and practice.

This module has been the standout unit of the MSc for me so far with clear and varied lectures; engaged peers and an engaging series of tutors; direction to thought provoking additional resources; insightful tailored feedback on formative assessments; and world-class guest speakers. I would thoroughly recommend it to any practicing clinicians who are looking to better understand the diagnostic process and when testing is and is not of benefit, and how they can utilise this to better care for their patients.