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versión impresa ISSN 1130-0108
Rev. esp. enferm. dig. vol.104 no.3 Madrid mar. 2012
Prospective analysis of clinician accuracy in the diagnosis of benign anorectal pathology: the value of clinical information
Análisis prospectivo de la precisión diagnóstica en la patología anorrectal benigna: importancia de la información clínica
Jaime Jimeno, Helena Vallverdú, Jaume Tubella, Cristina Sánchez-Pradell, Jordi Comajuncosas, Rolando Orbeal, Judit Hermoso, Pere Gris, José Luis López-Negre, Joan Urgellés and David Parés
Department of General and Digestive Surgery. Parc Sanitari Sant Joan de Déu. Sant Boi de Llobregat, Barcelona, Spain
This study was presented at the Scientific Meeting of the European Society of Coloproctology in Sorrento (Italy) 22nd-24th September 2010.
Aim: the prevalence of anorectal disorders in general population is high. The aim of this study was to analyze the influence of clinical symptoms on diagnostic accuracy for benign anorectal pathology among different specialists and evaluate the relationship between diagnostic accuracy and years of professional experience.
Methods: seven typical cases were selected. In a first interview, participants were shown images and asked to make a diagnosis. Afterwards, images with additional information (clinical symptoms) were used. Two groups (group 1 = general surgeons and group 2 = medical specialists who attended emergency department) completed both phases of the study to analyze the influence of clinical symptoms on the final diagnosis.
Results: forty four specialists were interviewed. The percentage of participants making a correct diagnosis in groups 1 and 2, respectively, was as follows: case 1 (perianal abscess): 100 vs. 80.6%, (p = 0.157); case 2 (fissure): 92.3 vs. 51.6% (p = 0.015); case 3 (thrombosed hemorrhoid): 92.3 vs. 74.2% (p = 0.321); case 4 (anal condyloma): 100 vs. 87.1% (p = 0.302); case 5 (rectal prolapse): 100 vs. 83.9% (p = 0.301); case 6 (prolapsed hemorrhoid): 92.3 vs. 29% (p = 0.001), and case 7 (fistula): 100 vs. 67.7% (p = 0.021). There were significant differences in the number of correctly diagnosed cases between groups (p < 0.001). Information about clinical symptoms significantly increased overall and specific accuracy. There was no correlation between experience and accuracy.
Conclusions: clinical symptoms are important for diagnostic accuracy in anorectal pathology. Training in anorectal pathology in medical specialists is warranted.
Key words: Anorectal diseases. Diagnostic accuracy. Education. Training.
Objetivo: la prevalencia de los trastornos anorrectales benignos en la población general es alta. El objetivo de este estudio es analizar la influencia de los síntomas clínicos en la precisión diagnóstica de la patología benigna anorrectal entre los diferentes especialistas y evaluar la relación entre el diagnóstico de la enfermedad y los años de experiencia profesional entre los profesionales participantes.
Pacientes y métodos: se seleccionaron 7 casos típicos. En una primera entrevista, se mostró a los participantes las imágenes clínicas de cada caso y se les pidió que formularan un diagnóstico. Posteriormente, se volvió a mostrar las mismas imágenes con información clínica adicional. Dos grupos (grupo 1 = especialistas en cirugía general y digestiva y grupo 2 = especialistas de especialidades médicas con asistencia en el área de urgencias) completaron las dos fases del estudio para analizar la influencia de los síntomas clínicos en el diagnóstico final. También se analizó la relación entre la precisión diagnóstica y los años de experiencia de cada profesional.
Resultados: se entrevistaron a 44 especialistas. El porcentaje de participantes que realizó un diagnóstico correcto en el grupo 1 y 2, fue respectivamente: caso 1 (absceso perianal): 100 vs. 80.6%, (p = 0,157); caso 2 (fisura anal): 92,3 vs. 51.6% (p = 0,015); caso 3 (hemorroide trombosada): 92,3 vs. 74,2% (p = 0,321); caso 4 (condiloma anal): 100 vs. 87,1% (p = 0,302); caso 5 (prolapso rectal): 100 vs. 83.9% (p = 0,301); caso 6 (prolapso hemorroidal): 92,3 vs. 29% (p = 0,001), y caso 7 (fístula perianal): 100 vs. 67,7% (p = 0,021). Se observaron diferencias en el número de los diagnósticos correctos entre grupos (p < 0,001). Globalmente, la información sobre síntomas clínicos incrementó significativamente la precisión específicamente, no observándose correlación entre experiencia profesional y precisión.
Conclusiones: los síntomas clínicos son importantes para la precisión diagnóstica de la patología anorrectal benigna. La formación específica de especialistas médicos en esta patología anorrectal está claramente justificada.
Palabras clave: Enfermedades anorrectales. Precisión diagnóstica. Educación. Formación.
The prevalence of anorectal disorders is high in the general population (1,2). Most of these patients are initially attended by medical specialists rather than surgeons, moreover on emergency setting (3). A high percentage of misdiagnosis in the management of this pathology has been reported and attributed to a lack of clinical training among non-surgical specialists (4,5).
Grucela et al. (6) performed an elegant study aiming to examine the diagnostic accuracy of clinicians in the diagnosis of common anal pathologic conditions. These authors demonstrated suboptimal accuracy among clinicians, which did not correlate with years of experience, providing strong evidence that more education and training in the identification of these disorders is required. However, a limitation of that study was that diagnosis was made only by viewing images with no information on clinical history.
The aim of this study was to prospectively analyze the value of clinical symptoms in diagnostic accuracy for benign anal pathology among practitioners from distinct specialties all of them attending patients in emergency department. The results were also assessed according to years of professional experience.
This study was approved by our institutional review board. Seven typical cases of benign anorectal disorders were used in this study. For educational purposes, the same entities as those used in a previous publication but with our own images were selected (6), consisting of the following diagnoses: perianal abscess, anal fissure, thrombosed external hemorrhoid, anal condyloma, full-thickness rectal prolapse, prolapsed internal hemorrhoid, and anal fistula.
Two certified colorectal surgeons prepared a structured text of simulated clinical records for each case, using a specific textbook of colorectal surgery (7). The participants were divided into two groups: group 1 consisted of specialists in general surgery and group 2 of physicians belonging to medical specialties including: general practice, internal medicine, emergency medicine, cardiology, pneumology and gastroenterology. All specialists included attended whole or in part, medical emergencies.
The study comprised two continuous evaluations of each selected case in all participating clinicians. In the first part (phase 1), the clinicians were shown only slides of clinical images and were asked to make a diagnosis within 30 seconds. As in the study by Grucela et al. (6), the participants provided free recall diagnoses on a blank line corresponding to each case. In the second part of the study (phase 2), immediately following the first evaluation, the same images were used but with additional information consisting of the simulated clinical records for each case. In table I we presented the symptoms of the selected 7 cases. The answer sheets were analyzed by an independent team member who has not on the cases presentations. An example of images used with the clinical history is shown in figure 1.
Quantitative data are expressed as absolute numbers or median values. Categorical variables are presented as absolute numbers or percentages. Comparison of qualitative data and continuous variables was performed by means of the Mann-Whitney U test and two-tailed Fisher's exact test, respectively. The correlation of quantitative variables was analyzed using Spearman's correlation test. A bilateral p-value of less than 0.05 was considered statistically significant. The statistical analysis was performed using SPSS™ version 14.0 (SPSS™ Chicago, Illinois, USA).
Forty-four specialists were interviewed (13 in group 1 and 31 in group 2). Group 2 was composed of practitioners in the following specialties: general practice (n = 14), internal medicine (n = 9), emergency medicine (n = 5), cardiology (n = 1), pneumology (n = 1) and gastroenterology (n = 1). All of them attended whole or in part medical emergencies. There were significant differences in the median years of clinical experience in attending patients with anal disorders among the groups -group 1; 15.9 years (range 3-30) vs. group 2; 8.8 years (range 1-22), p = 0.021-.
Tables I and II show the overall results for diagnostic accuracy in both groups in the two phases of the study, respectively. Diagnosis was significantly more accurate in group 1 in three of the seven cases in phase 1 (Table II) but in only one out of the seven cases in phase 2 (Table III).
Information about clinical symptoms (phase 2) significantly increased diagnostic accuracy in group 2 (Table IV). The median number of correct diagnoses was 7.0 and 5.0 for groups 1 and 2 respectively (p < 0.001) when images were used, and was 7.0 and 6.0 when images and clinical symptoms were presented (p < 0.001).
As shown in figure 2, there was no correlation between years of clinical practice and diagnostic accuracy in either group when analyzed separately.
In agreement with previous research, this study found a lack of knowledge of benign anorectal disorders among non-surgical specialties (6). Moreover, we provide evidence that clinical symptoms have a greater influence on diagnostic accuracy for this pathology than years of clinical experience. Training in the diagnostic approach to benign anorectal pathology among physicians is therefore warranted including clinical symptoms and clinical images because both are important for diagnostic accuracy in these disorders.
Benign anal conditions are highly prevalent in the general population (2,8). Hence, all physicians, whatever their specialty, will potentially attend patients with anorectal pathology. It is well known that most of these patients are initially attended by medical specialists rather than by surgeons (3). Curiously, some studies have reported a high percentage of misdiagnosis in this pathology, due to lack of awareness or clinical training among non-surgical specialists (4).
In a previous study has been demonstrated the low percentage of diagnostic accuracy achieved among medical specialists, providing strong evidence that more education on the identification of this pathology is required (6). In this study, medical students were used as a control group, also demonstrating the low level of training in the diagnosis of benign anal diseases in this group.
A structured training plan for benign anal diseases is clearly required (9). The question arises of when medical specialists should be trained in proctological diseases. Despite the efforts of medical schools in this area, the level of training in anorectal disorders among students seems insufficient. In a study performed in Finland, final year medical students were tested in 10 minor surgical procedures, including rubber-band ligation of hemorrhoids. Although this is a specific procedure that requires more than theoretical knowledge, it can be used as a reference for comparison with other procedures such as abdominal paracentesis or urinary tract catheterization. The results of questionnaires indicate that rubber-band ligation of hemorrhoids is one of the least known procedures among students and was performed by only 4% (10). The level of knowledge of this pathology in the control group (consisting of students) in Grucela's study was poor also (6). Therefore, there is no doubt that the first step is to increase training in the diagnosis and treatment of benign anal diseases in medical schools.
Knowledge of benign anal disorders in primary care is less known, despite the importance of awareness of these disorders among primary care physicians to patient comfort and referral to specialists (5). Fourteen of the participants in our study were general practitioners. In a study performed in Spain the diagnostic accuracy of general practitioners in a sample of patients referred to specialists was recently assessed. Interestingly, diagnosis of hemorrhoids was much better than that of anal fistula or anal fissure. The Kappa index in this latter diagnosis was particularly poor (11). Participants in our study also found anal fissure especially difficult to recognize. Since general practitioners will probably be the first to attend these highly prevalent disorders, these clinicians should probably spend some time in a general surgery department, as occurs for example in Spain (11).
An important finding of our study is the value of the clinical history in the diagnosis of benign anorectal conditions. Indeed, when appropriate questions are asked in structured format, the physical examination it is only an adjuvant part of accurate diagnosis. In our study, we found no correlation between years of experience and the number of cases resolved. In contrast, when clinical information was provided, the diagnostic accuracy of all participants in this study improved.
While misdiagnosis of benign anal pathology usually is not dangerous, a delayed diagnosis or erroneous treatment could trigger chronicity and lead to increased health services utilization and impaired quality of life (12). Accurate diagnosis, however, is essential in patients with rectal cancer (13). Consequently, physical examination is of paramount importance in every patient, especially when gastrointestinal bleeding is present (14).
The strength of our study lies in the addition of clinical information to physical examination represented by images. This method is highly representative of real cases and could constitute a model for clinical training. A limitation of this study is that the non-surgical sample (group 2) consisted of practitioners from distinct specialties and with distinct years of clinical experience. We did, however, achieve our aim of determining the value of training over years of experience. Also we will study, in an ongoing study, the same study performed only in general practitioners in order to analyze their diagnostic accuracy in health primary care.
In conclusion, information on clinical symptoms is important for diagnostic accuracy in anorectal pathology in medical specialists and surgeons, irrespective years of clinical experience. Therefore, training in anorectal pathology among medical specialists is warranted. Such training should begin in the first years of medical studies and continue in the first years of each residency program. Training methods with simulated cases including clinical images and information on clinical symptoms should be used.
The authors thank the clinicians who participated in this study. The authors would also like to thank Gail Craigie for editorial support.
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Department of General and Digestive Surgery.
Parc Sanitari Sant Joan de Déu.
C/ Camí Vell de la Colònia.
08830 Sant Boi de Llobregat. Barcelona, Spain.