|Year : 2018 | Volume
| Issue : 2 | Page : 41-43
Viral infectious diseases: Specialist perspectives on learning about diagnosis and differential diagnosis
BMJ Knowledge Centre, BMJ Publishing Group, London, UK
|Date of Web Publication||7-Feb-2019|
Dr. Kieran Walsh
BMA House, Tavistock Square, London WC1H 9JR
Source of Support: None, Conflict of Interest: None
Background: Making a diagnosis of infectious disease requires knowledge of the symptoms, signs, and diagnostic tests associated with that disease. Many healthcare professionals use online clinical decision support resources to help learn how to make a diagnosis. One common and popular resource is BMJ Best Practice. The purpose of this paper is to share educational themes that can be drawn from the BMJ Best Practice clinical decision support resource. Methods: Documentary research was conducted on the diagnostic approach sections of the top 10 most viewed infectious disease topics. Topics included HIV, hepatitis B virus (HBV), infectious mononucleosis, hepatitis C, dengue, hepatitis A, influenza, measles, avian influenza, and Ebola. Results: Seven key themes emerged as follows: Clinical features remain paramount in learning about the diagnosis of infectious disease and elicitation of risk factors (including travel history) are an important part of the clinical history. Diagnosis is important in and of itself but is also important as a step toward notification, public health surveillance, and infection control measures. The differential diagnosis and coinfection are important considerations when learning how to diagnose infectious diseases as is the precise phase or stage of the disease in question. Conclusions: Much of the medical education literature focuses on the instructional design within the resources, rather than the actual content within the resources. This article attempts to redress this gap in the literature by describing the results of a detailed analysis of the content.
Keywords: Diagnosis, differential diagnosis, infectious diseases
|How to cite this article:|
Walsh K. Viral infectious diseases: Specialist perspectives on learning about diagnosis and differential diagnosis. Educ Health Prof 2018;1:41-3
|How to cite this URL:|
Walsh K. Viral infectious diseases: Specialist perspectives on learning about diagnosis and differential diagnosis. Educ Health Prof [serial online] 2018 [cited 2019 Apr 25];1:41-3. Available from: http://www.ehpjournal.com/text.asp?2018/1/2/41/251900
| Introduction|| |
Much of medicine is about making a diagnosis. However, making a diagnosis is not always straightforward – especially when dealing with infectious diseases. Making a diagnosis of infectious disease requires knowledge of the symptoms, signs, and diagnostic tests associated with that disease. To help them learn how to make a diagnosis, many healthcare professionals use online clinical decision support resources.
BMJ Best Practice is the clinical decision support tool of the BMJ. It has created clinical decision support resources to help doctors and other health-care professionals diagnose both common and rare infectious diseases. These resources concentrate predominantly on the tangible knowledge that is needed to make such diagnoses. The resources are mainly text-based and available online. They are written by international experts in their relevant fields and are independently peer reviewed. The resources cover infectious disease topics comprehensively – from epidemiology to diagnosis, management, and prognosis. There is a section of the content entitled diagnostic approach – where the expert delivers a narrative on how to approach the diagnosis of the relevant disease. This section is important as it covers more than just the diagnostic facts – it also delves into the priorities that the health-care professional should consider when learning how to diagnose a relevant patient. This article examines the content in this section of the infectious disease topics – to find out what commonalities exist between the suggested diagnostic approaches among the various topics. The purpose of the paper is to share the educational themes that are important when learning about diagnosis and differential diagnosis – so that other healthcare professionals can use similar themes in their educational activities.
| Methods|| |
The top 10 most viewed topics were analyzed. These were the topics on HIV, hepatitis B virus (HBV), infectious mononucleosis, hepatitis C, dengue, hepatitis A, influenza, measles, avian influenza, and Ebola. The documentary research was conducted on the diagnostic approach sections of these topics, and these were analyzed from a positivist perspective. In keeping with this perspective, the process involved close adherence to what can be objectively viewed and quantified and the themes that can be drawn from the content.
| Results|| |
Seven key themes emerged from this analysis are as follows:
Theme 1: Clinical features remain paramount in learning about the diagnosis of infectious disease
It is clear from the content that clinical features remain vitally important in learning about the diagnosis of these infectious diseases. Thus, a thorough history and examination to discover relevant symptoms and signs are vital – even though a consistent theme is that there are few pathognomonic features and that generally diagnoses are made on the balance of probabilities from clinical features. Another key aspect of the clinical history is any history of exposure or risk factors for exposure to the infection in question. Risk factors may be related to the patient's occupation, social background, or lifestyle. One section included the following statement: “during a known influenza outbreak, any person with acute fever and respiratory symptoms should be considered to possibly have influenza and can usually be diagnosed clinically with a high degree of certainty.” Another section included the following statement: “the diagnostic approach to measles begins with obtaining a history of potential exposures and risk factors, performing a detailed physical examination, applying clinical definitions, and obtaining, if necessary, laboratory tests to confirm the diagnosis.”
Theme 2: Travel history as a risk factor
Another theme that can be drawn from these sections is the importance of learning how to take a detailed travel history. The relevant content sections continually mention the importance of taking a detailed travel history to make the correct diagnosis. One section included the following statement: “a recent history of travel to an HPAI-H5N1 virus-affected country should also prompt consideration of HPAI-H5N1 virus infection in the differential diagnosis of a patient presenting with fever and respiratory symptoms.” Another section included the following statement: “a diagnosis of dengue should be suspected in any patients residing in countries where dengue infection is endemic or traveling from such areas within the past 2 weeks.”
Theme 3: Diagnosis as a step toward notification
Another theme that can be drawn from these sections is that diagnosis can be an important step in notifying authorities of the disease. This is clearly seen as a priority to prevent further spread of the infectious disease. Various sections included the following statements: “novel influenza A virus infections are a notifiable disease in the US and some other countries;” “hepatitis C is a notifiable disease in the US and some other countries.”
Theme 4: The purpose of diagnostic tests might be clinical management or public health surveillance
It is important for learners to realize that the purpose of the diagnostic tests might be clinical management but is often public health surveillance, research, or epidemiology. The same is true of certain case definitions – they are often more useful in epidemiological studies than they are in actual clinical management. One section on diagnostic tests to detect hepatitis A virus RNA in stool, body fluids, serum, and liver tissue included the following statement: “these are not often necessary and serve only as adjunct tools in research laboratory settings.” One section on diagnostic tests in the influenza topic included the following statement: “it is not often used for initial clinical management as results may take up to 72 h to be reported. Rather, it is used for confirming screening tests and for public health surveillance.”
Theme 5: The diagnostic pathway to infection control measures
The diagnosis of an infectious disease is important for the affected patient but can also have implications for other patients, the health-care staff caring for the patient, and for the wider public. This is because the patient may infect people from any of these groups. Learning about this is vitally important. One section on Ebola included the following statement: “infection control risk should be assessed. Having determined that a patient may be infected, the physician needs to determine how infectious the patient is currently.” Another section on influenza included the following statement: “identifying that a symptomatic patient may be at risk of infection mandates precautionary isolation procedures and use of personal protective equipment until the infection is either confirmed or excluded. It is extremely important to minimize the risk of transmission while working up the patient. If there is concern that a patient might have HPAI H5N1 virus infection, infection control precautions should be used, including face mask, goggles, disposable gown, and gloves.”
Theme 6: The phase or stage of the disease is a core component of learning how to make a diagnosis
Many infectious diseases pass through different phases or stages. These may include a prodromal or asymptomatic phase, acute phase, chronic phase and recovery phase or complications phase. It is important to learn that the clinical features of the disease and the results of investigations will vary depending on the phase of the disease that the patient is in. One section in the avian influenza topic included the following statement: “early illness is manifested by signs and symptoms consistent with a febrile upper respiratory tract infection.” One section in the Ebola topic included the following statement: “the initial presentation is nonspecific, which makes early clinical diagnosis difficult.” Another section included this statement: “the serological profiles are helpful in differentiating between acute and chronic HBV infection.”
Theme 7: The importance of differential diagnosis and coinfection
The consideration of differential diagnosis and co-infection is core to coming to a correct diagnosis of an infectious disease. Many infectious diseases have a broad range of potential differentials. Coinfection with more than one pathogen is also not uncommon. The focus of learning about the history, examination, and investigations should be on excluding certain diseases as well as diagnosing others. Various sections included the following statements: “the case definition for Ebola virus infection is very broad and includes a long list of possible differential diagnoses;” “co-infection with malaria was seen in up to 5% of patients in West Africa during the 2014 (Ebola) outbreak, so the possibility of dual infection should be considered in all patients.” The relevant section in the avian influenza topic included the following statement: “sputum Gram stain and bacterial culture, and blood culture should be performed as part of the evaluation for primary bacterial pneumonia and potential bacterial coinfection.”
| Discussion|| |
A number of key themes emerged from this analysis of clinical decision support educational content on the diagnosis of infectious diseases. Clinical features remain paramount in learning about the diagnosis of infectious disease, and elicitation of risk factors (including travel history) is an important part of the clinical history. Diagnosis is important in and of itself but is also important as a step toward notification, public health surveillance, and infection control measures. The differential diagnosis and coinfection are important considerations when learning how to diagnose infectious diseases as is the precise phase or stage of the disease in question.
There is now a large body of literature on online medical education. Much of this literature focuses on the instructional design within the resources, for example, the degree of interactivity or multimedia in the learning. However, there is a dearth of literature that examines the actual content within the resources. This is surprising as the content is core to education. This paper attempts to redress this gap in the literature by describing the results of a detailed analysis of the content.
There are limitations to this analysis. The analysis looked only at clinical decision support educational resources from a single provider and looked only at ten clinical decision support resources. However, these resources were created by experts from a variety of different institutions and were independently peer reviewed. Even though only ten resources were analyzed, these were the ten most accessed topics.
As with all forms of documentary analysis, the challenge is as much to discover what is missing as it is to analyze what is there. It is telling that there is mention of investigations in all the content that was analyzed, but sophisticated investigations do not dominate the text. This is somewhat surprising given the volume of literature on the latest high technology diagnostic investigations., By contrast, analysis of the content suggests the importance of learning clinical acumen in diagnosis, and that diagnosis must be seen in the context of the clinical pathway that leads toward notification, infection control, and management. The ultimate purpose of online clinical decision support and educational resources is to help health-care professionals practice evidence-based medicine and put guidelines into action for the benefit of patients. To achieve this, online clinical decision support education must put clinical insight and judgment at the heart of its resources.
Financial support and sponsorship
Conflicts of interest
Kieran Walsh works for BMJ which produces a range of educational content in infectious and non-infectious diseases.
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