Introduction
A central goal of medical training is that qualified consultants should practice to the same gold standard, dictated by the speciality curriculum. In an ideal world, practice of consultants should be uniform. In practice, there will inevitably be differences stemming from multiple factors, including the complexity and nuance of medical disorders and presentations, differences in training and exposure to conditions during training, sub-specialization interests, personal philosophy in terms of investigative approach (based on managing clinical risk and access to tests), and duration of clinical experience.
Perhaps surprisingly, there are relatively few research studies focusing on inter-rater variation in consultant practice in neurology, or any other specialty, especially in a real-world outpatient setting, in which uncertainty, balancing risks and benefits, and making clinical judgements, often in the face of incomplete information, are characteristic. Previous studies have tended to focus on approach to single symptoms or diseases, such as classification of dysarthria from speech recordings1, management of Alzheimer’s disease and vascular dementia2, or skills in eliciting neurological signs3. Aspects such as clinical experience and diagnostic confidence have been studied; greater experience was associated with greater diagnostic confidence in patients with medically unexplained symptoms4. However, in real-world neurological practice, patients present with heterogeneous and undifferentiated problems, with varying quantity and quality accompanying data available. Consultants may rely, to a greater or lesser degree, on their clinical assessment, supported by investigations, the latter an expensive and finite resource. At the end of the clinical encounter, regardless of approach, the goal is that the patient receives an accurate diagnosis.
The primary aim of this study was to evaluate systematically similarities and differences in practice between consultant neurologists with differing levels of clinical experience, applied to a large series of consecutive patients seen in the general neurology outpatient setting by a newly qualified consultant neurologist, both in terms of diagnosis and investigative approach. The null hypothesis was that diagnosis, and investigations, would be uniform across participants. The alternative hypothesis was that differences in management approach would emerge, which could then be explored for practical utility as a potential tool for appraisal.