Researching and supporting decision making in primary care: Developing an educational intervention with web-based patient vignettes

 Funded by NIHR Policy Research Programme (The Policy Research Unit in Cancer Awareness, Screening, and Early Diagnosis)

September 2011 - December 2018

Principal Investigators: Professor Rosalind Raine, Dr Jessica Sheringham

Key contacts: Dr Angelos Kassianos, Ruth Plackett

Partners and collaborators involved: UCL, QMUL

Project summary

Improving earlier diagnosis of cancer and reducing inequalities is a priority for NHS England to address this country’s comparatively poor cancer survival. This research first sought to understand how GPs decide which patients with common symptoms that might be lung cancer should have cancer investigations.

RESEARCH: We used an innovative method to study GP behaviour. A sample of GPs were asked to conduct simulated consultations delivered through an interactive website. They first watched a short video of patient actors reporting a symptom that might indicate lung cancer. They then sought further information on the ‘patients’ by typing in questions or selecting options on the website. At the end of the ‘consultation’, GPs recorded their management decisions. This study indicated that GPs were not more likely to investigate ‘patients’ with high-risk than low-risk cancer symptoms. Furthermore, they did not investigate everyone with the same symptoms equally. Our findings suggest that insufficient data gathering could be responsible for missed opportunities in diagnosis.

· Research paper: Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes

· Research online application: A short demonstration video

EDUCATION: The next phase of this work seeks to address these findings. The eCREST (electronic Clinical Reasoning Educational Simulation Tool) has been developed, initially for future doctors, i.e. medical students in their final year.

This online tool combines virtual patients - videos of actors representing patients to simulate a doctor-patient consultation in a GP setting – with reflective prompts and feedback to enable students to develop and practise the thought processes that doctors use to make clinical decisions whether to order cancer investigations.


Initial testing in the UK and internationally (UCL, Barts and Koc, Istanbul) indicates it is valued by students and helped them decide what to ask patients and reach a more informed differential diagnosis:

“Instead of worrying about what to ask, it [eCREST] helps you to focus on what might be relevant. Even if your question is irrelevant, you can still hear patient’s response and see the outcome…Loved it!"

Comment from a recently qualified medical student who tested eCREST

· eCREST online educational tool: short demonstration video TO FOLLOW