title: General practitioners' reasoning when considering the diagnosis heart failure: a think-aloud study.
abstract: BACKGROUND
  Diagnosing chronic heart failure is difficult, especially in mild cases or early in the course of the disease, and guidelines are not easily implemented in everyday practice. The aim of this study was to investigate general practitioners' diagnostic reasoning about patients with suspected chronic heart failure in comparison with recommendations in European guidelines.
  
  
  METHODS
  Think-aloud technique was used. Fifteen general practitioners reasoned about six case vignettes, representing authentic patients with suspected chronic heart failure. Information about each case was added successively in five steps. The general practitioners said their thoughts aloud while reasoning about the probability of the patient having chronic heart failure, and tried to decide about the diagnosis. Arguments for and against chronic heart failure were analysed and compared to recommendations in guidelines.
  
  
  RESULTS
  Information about ejection fraction was the most frequent diagnostic argument, followed by information about cardiac enlargement or pulmonary congestion on chest X-ray. However, in a third of the judgement situations, no information about echocardiography was utilized in the general practitioners' diagnostic reasoning. Only three of the 15 doctors used information about a normal electrocardiography as an argument against chronic heart failure. Information about other cardio-vascular diseases was frequently used as a diagnostic argument.
  
  
  CONCLUSIONS
  The clinical information was not utilized to the extent recommended in guidelines. Some implications of our study are that 1) general practitioners need more information about how to utilize echocardiography when diagnosing chronic heart failure, 2) guidelines ought to give more importance to information about other cardio-vascular diseases in the diagnostic reasoning, and 3) guidelines ought to treat the topic of diastolic heart failure in a clearer way.
authors.affiliation: Department of Clinical Sciences, Center of Family Medicine (CeFAM), Karolinska Institutet, Stockholm, Sweden. ylva.skaner@klinvet.ki.se
authors.forename: Ylva
authors.initials: Y
authors.lastname: Skånér
authors.forename: Lars
authors.initials: L
authors.lastname: Backlund
authors.forename: Henry
authors.initials: H
authors.lastname: Montgomery
authors.forename: Johan
authors.initials: J
authors.lastname: Bring
authors.forename: Lars-Erik
authors.initials: LE
authors.lastname: Strender
mesh_terms: D003071:Cognition; D003142:Communication; D003657:Decision Making; D004452:Echocardiography / Q000706:statistics & numerical data; D005060:Europe; D006333:Heart Failure / Q000175:diagnosis* / Q000000981:diagnostic imaging; D006801:Humans; D007600:Judgment; D008487:Medical History Taking; D010821:Physicians, Family; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D011237:Predictive Value of Tests; D011336:Probability; D013548:Sweden