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.