Institute of Epidemiology & Health Care


Supporting decision making in primary care

Supporting decision making in primary care: An interactive educational resource using online patient cases

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

Duration: September 2011 - June 2019

Principal Investigators: Professor Rosalind Raine, Dr Jessica Sheringham

Key contacts: Dr Angelos Kassianos, Ruth Plackett

Partners and collaborators involved: UCL, QMUL, University of Exeter, Barts & The London School of Medicine, University of East Anglia Medical School.

Project summary

Improving earlier diagnosis of cancer and reducing inequalities is a priority for the NHS in England. Our research first sought to understand how GPs decide which patients with common symptoms that might be lung cancer should have cancer investigations and then sought to support decision making in future doctors through development of a novel educational resource.


We used an innovative method to study GP behaviour. GPs participants conducted 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 found that GPs were more likely to investigate ‘patients’ when they had elicited information about symptoms that patients did not volunteer. Our findings suggest that insufficient data gathering could be responsible for missed opportunities in diagnosis.


In the next phase of this work, we developed an educational resource: eCREST (electronic Clinical Reasoning Educational Simulation Tool), 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.


Early results from testing in the UK and internationally (in 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

View a video demonstration of the eCREST online educational tool
UPDATE (March 2019): A feasibility trial in three UK medical schools was recently completed. Data from the trial are currently being analysed.

NEWS: We are currently working with EDUCATE, a programme for promising educational technology innovations to explore opportunities to scale up the use and testing of eCREST, which includes testing with other student groups. Contact the eCREST team if you’d like to discuss testing or using eCREST for students in your setting.