07 MRS – Problem definition 2: “hypothesis testing” (the diagnostic process)

Main Scale

The doctor generates ideas superficially, and tests them in random order. If the first idea proves to be wrong he does not know what to do next, and tends to end the consultation quickly and inappropriately. The order in which the doctor generates and tests ideas is ‘weighted’ by probability and seriousness. The collapse of one leads logically to the next. He/she ends the consultation only when the problem has been adequately defined.
1 2 3 4 5 6 7 8 9 10
Has little understanding of this. Attempts to do this but is not yet skilful and sometimes runs into difficulty. Attempts to do this and is usually successful but recognises his/her limitations. Perfect


The doctor:

Rarely Occas
Often Usually
(a) Bases his/her weightings on a sound estimate of frequency and probability.
(b) Uses sound clinical judgement to assess the degree of seriousness.
(c) Examines his/her hypothesis systematically ( eg “if there is not a primary cause of heart failure let us look at secondary causes.”)

Notes for raters

Ideas about the nature of the problem, i.e. hypotheses have been shown to beformed very early in the consultation: as soon as two or three symptoms havebeen offered the doctor thinks: “It sounds like (a) but it could be (b); onthe other hand I mustn’t forget that it could be (c), which is unlikely but soserious that I must exclude it. The rest of the data collection (by historytaking, physical examination and if necessary laboratory tests or X-rays) isdirected towards testing those hypotheses .

This area is best assessed by examining what further information is sought(in case discussion, or MEQ’s and asking: “why did you ask …?”,”why did you examine …?”. When sitting in, early and inappropriateendings are easily seen.




  • Sheldon M, Brooke J and Rector A (1985) Decision Making in General Practice. London, Macmillan.
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