Clinical diagnosis by junior doctors - How confident and accurate are they.

Background: Accurate diagnosis is necessary for effective treatment. Over the past few years it has been noticed that the junior doctors are not confident enough to make a diagnosis after initial history and examination. Aim of this study is to determine the ability of junior doctors to document a clinical diagnosis and accuracy of the diagnosis. Method: This single centre study included case records of patients admitted to Professorial Medical Unit (PMU) and Emergency Treatment Unit (ETU) at Colombo South Teaching Hospital (CSTH). The junior doctors‘ on admission diagnosis is compared with the medical consultants‘ diagnosis. Only case records of patients belonging to four common specialty domains were studied. Results: In the PMU out of 200 case records no diagnosis or symptom as a diagnosis was documented in 99(49.5%) cases and a diagnosis was documented in 68(34.0%) case records of which 53(77.9%) diagnoses were concordant with the medical consultants‘ diagnosis. When case records of patients admitted to ETU considered, no diagnosis or symptom as a diagnosis was documented in 56(56.0%) case records and a diagnosis was documented in only 21(21.0%) case records of which 15(71.4%) diagnoses were concordant with the medical consultants‘ diagnosis. Documentation of correct diagnosis improved with the grade of the doctor, from intern medical officer (IMO) to medical registrar (MR) in both study settings and also with the order of clerking. Conclusion: Recording of symptom based diagnosis or no diagnosis remains high among most of the junior doctors in all specialty domains and at all grades.