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