clinical approach in family medicine.pptx
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Clinical Approach in Family Medicine
Dr. Badria El Faki
The approach and caring for patients by family physicians require a different emphasis in skills and attitudes than the one used in hospital based care
Because family physicians provide a wide spectrum of care, which includes › Anticipatory care › Symptomatic care › Therapeutic care› Palliative care
At all ages, both sexes, at many sites beside their offices
Clinical approach in family medicine
Comes in three ways:› Problem solving› Consultation› Communication
Problem solving
A. Problem Solving
I. Inductive Reasoning method: The classical method which is taught in medical schools when
approaching a pt which is:1. Doctor-centered, In which the physician tries to
accomplish his own agenda, including; History of presenting illness Full symptoms enquiry Past medical, drug, family and social Hx Extensive lab. Investigations Diagnosis of a specific disease
oh here’s the problem !
I.Inductive Reasoning method (cont’d)
1. Doctor-centered2. Disease-oriented, in which the physician
is concerned about the diagnosis not the total patient as a human being through;
Biomedical approach which aims to diagnose or exclude organic diseases
Managing a specific disease.
Limitations of the Inductive Reasoning Method
Acceptable for undergraduate level aiming for learning a wide range of questions and maneuvers in clinical examination.
Can raise problems for family physicians because of the following a) Undifferentiated nature of the presenting
problem; no specific diagnosis can be reached in 50 % of family medicine consultations because of early presentation, multiple problem, interaction of physical, emotional and social factors
Limitations of the Inductive Reasoning Method cont’d.
a) Undifferentiated nature of the presenting problem.
b) Inductive method forces the physician to interpret the presenting symptoms and signs in terms of a specific disease , which may lead to misdiagnosis or over diagnosis, which in turn may lead to. increase stress, anxiety and unnecessary cost
c) Pushes the physician to ask questions and not listen actively to his patient.
d) May be suitable in hospitals, but not in family medicine.
A. Problem Solving cont’d
II. Hypothetical-deductive method:
Recent studies support the suggestion that a physicians should formulate his/her hypothesis early in the consultation, based on verbal and non-verbal clues, previous experiences, patient medical records and patient in the family contexts.
Existing clues
Presenting Clues
PROVISIONAL DIAGNOSIS
Support
Clinical evaluation(history & physical
examination)(further clues supplied or
sought)
Stage IIHypothesis formulation
Stage IData collection
Stage IIIHypothesis testing
Stage IVDiagnosis/Problem definition
Stage VManagement
Stage VIOutcome Evaluation
hypothesis
No support
CRAPRIOP(further clues
supplied or sought)
No support Outcome
Hypothesis revision
Fig.1: Model of hypothetical –deductive method for problem solving
Stage I. Data collection & analysis of presenting & existing clues
Sources of clues;1. The patient2. The relatives or other significant members ( friends,
neighbours)3. Medical Records 4. Other Sources
Types of clues; can be in the form of: Symptoms Body language Age Ethnic group Thick / Thin records Subjective
Weighing of clues
The role of clues in diagnosis depends on the following factors:› Significance › Pattern › Seriousness › Proability
Role of physician at this stage ( Stage I)
Identify all patient problems
Identify the context of the problems
Understand the patient as a whole
Stage II. Hypothesis formulation & developing professional diagnosis
Recommended to formulate 5-7 hypothesis at the beginning of the consultation then refine them.
As the consultation proceeds you may not find a support for the targeted hypothesis which should be revised.
New ideas may be raised during consultation which need to be tested.
During this stage you should keep taking decisions based on your findings .
Stage III. Hypothesis Testing
Further information is obtained by history taking and physical examination to rule in or out the initial hypothesis.
Taking into account biological, psychological and social terms.
Consider the following:1. Verbal and non verbal clues 2. Best hypothesis (working diagnosis)3. Evidence for and against each working diagnosis4. Select diagnostic tests on two bases
a) Specificity & sensitivityb) Efficacy, safety & cost
Stage IV. Diagnosis (problem definition)
It is not always possible to reach a definite diagnosis in family medicine.
Hence you have to learn how to live with uncertainty by stating the patients “bio-psycho-social” problem/diagnosis.
Stage V. Management Options
Manage your patient (not the disease) by using the CRAPRIOP acronym as follows;
C: clarify R: reassureA: advise the patient P: prescribe R: referI : investigateO: observeP : prevent
Stage VI. Outcome Evaluation
The diagnosis physicians could check if the outcome of this
management support the working diagnosis or there is a need to revise the hypothesis.
The physician as a physician you have to take care of yourself in
the form of › Housekeeping esp. after difficult consultations› Self updating
The setting Regular clinical auditing
THANK YOU V MUCH
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