the clinical method in family medicine
DESCRIPTION
The Clinical Method in Family Medicine. Introduction to Primary Care: a course of the Center of Post Graduate Studies i n FM. PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847. Aims-Objectives. Aim: the participants will have knowledge on the patient centered clinical method. - PowerPoint PPT PresentationTRANSCRIPT
The Clinical Method The Clinical Method in Family Medicinein Family Medicine
Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847
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Aims-Objectives
• Aim: the participants will have knowledge on the patient centered clinical method.
• Objectives: be able to– state Levenstein’s patient centered
clinical method principles – discuss the diagnostic process in family
practice– describe the common errors done during
a diagnostic process– discuss how time can be used as a
diagnostic tool in general practice
What are the methods physician used to solve
problems?
McWhinney, 1997
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Pattern recognition
• e.g. Childhood eczema• a distinctive appearance and distribution, affecting
mainly the flexures of the wrists, the elbows and the backs of the knees.
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Algorithms
• Clinical reasoning that proceeds systematically through branching decision
points
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Algorithms
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Inductive reasoning methods
Chief Complaint
History of The Present Complaint
Past Medical History
Family History
Personal & Social HistoryDrug & Allergy History Systems Review
Physical Examination
Biological Diagnosis
Disease Management:
Investigation
Prescribing
Follow-up Appoint
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• Doctors – centered (concentrate on doctors –agenda)
• Biomedical approach (aims to diagnose or exclude organic disease
• Managing a specific disease
• What else?
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Hypothetical deductive reasoning method
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Hypothetical deductive reasoning method
• e.g. a patient presents with a fever productive cough and decreased appetite.
• The hypothesis :– pneumonia, – bronchitis or– an upper respiratory infection (URI).
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We collect some data to help us confirm or reject our
hypothesis. The data tell us that our patient has high
temperature and some rhonchi at the right base on
auscultation.
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• We decide that’s not quite enough information on which to base a decision, so we also order a chest X-ray. It shows a right lower lobe infiltrate. We’re then able to confirm our diagnosis of pneumonia.
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The diagnostic process
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Clues
Hypothesis
Investigation
Finding commmon ground
Management decision
Follow up
Unexpected cluesReview
Relative contributions to the diagnosis
• In medical OPD: – history alone determine the diagnosis
in 56 % of all referral made (27-56%)– Physical examination : 17 % (0-24%)– Routine investigation: 5% (0-17%)– Special investigations: 18% (6-58%)– Routine CBC & urinalysis: 1%
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Generating and ranking appropriate diagnostic possibilities
• Probability: (the most likely)• Seriousness: (the average GP is likely to encounter a
malignant melanoma only once or twice in a professional lifetime, so suspicion should be genius.
• Treatability: hypothyroidism is an uncommon cause of tiredness but it should not be overlooked as it is readily corrected by replacement therapy
• Novelty: e.g pheochromocytoma as a cause of hypertension
• 5 : 2 ratio (most likely: less likely but important to consider)
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How can we apply this methodin family practice?
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Patient Presents Problem (s)
Parallel search of two frameworks
Disease Framework
The Doctors Agenda
Symptoms
Signs
Investigations
Pathology
Gathering Information
Illness Framework
The Patients Agenda
Ideas
Concerns
Expectations
Feelings
Thoughts
EffectsDifferential Diagnosis
Understanding the patient’s unique experience of their problem(s)
Integrating the two frameworks
Explanation & planning
Reaching a shared understanding & decision-making
The Disease - Illness ModelThe Disease - Illness ModelLevenstein’s model, McWhinney 1984
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Levenstein’s model (1984)
1. Evaluating both the disease and the illness experience
– Differential diagnosis– Extent of disease
(effect on the feelings, expectations, ideas and functions of the patient)
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Disease Illness
“Differentiated”
• Signs and symptoms
• Abnormal tests
• A “classification”
“Unique personal experience”
• Feelings
• Expectations
• Fuctions…
• Illness is a personal perception
Doctor waves back and forth
Example: increased cholesterol
• Disease– CAD, past MI– Obesity– Hypercholesterole
mia– Rule out
depresssion
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• Illness– Ideas: no longer a healthy
man
– Feelings: fear of inability to participate family activities or even a second MI
– Expectations: co-operation with doctor regarding diet
– Functions: walks 6 km per day. Returned to work. Sexual activity needs to be explored
2. Understanding the whole person– “as a person” (life story, personal and
developmental conditions)– Context (anybody being effected from the
patients condition, physical environment)
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Disease
Illness
Person
Environment
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3. Finding common ground with the patient about the problem and its management
– Problems and priorities– Treatment goals– Roles of doctor and patient in the treatment
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4. Incorporating prevention and health promotion
– Health promotion– Risk reduction– Early diagnosis– Decreasing complications
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5. Enhancing the doctor-patient relationship
– Features of the therapeutic relationship– Sharing of power– Care and cure– Self awareness– Transference and countertransference
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6. Being realistic– Time– Resources– Team
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Mr. Farouk, a 36-years old bank manager, come to see you. He has been a practice patient for 3 years. You have seen him only once for a routine health check 6 month previously when no problems were identified. He asked to see you urgently today. He like worried and tells you that while driving to an appointment earlier today he developed a pain in his neck, which spread to his back and chest. The pains have persisted and he has now developed “tingling” in his hands and face.
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Q1. What are your initial hypotheses? Explain why
you arrived at these?
Most likely hypotheses:
Less likely hypotheses:
Q2. What questions you want to ask to test
your hypotheses?
You learn that Mr. Farouk has been under a great deal of stress at work. He is working a continuous 10-hour/day and then taking work home. The pain has started gradually some 2 hours previously when he was on his way to an important customer who was threatening to transfer his account. He is worried that he has had a heart attack. There are no other positive features in the history.
Q3. What is your hypothesis now? How did you arrive at these?
Most likely hypotheses:
Less likely hypotheses:
Q4. What physical exam you are going to perform?30
Mr. Farouk was obviously anxious during the
interview but relaxed during the examination. His
pain and tingling have now gone. You have found
no specific abnormality on examination.
Q5 What is your management?
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Common errors in diagnostic process
• Unwarranted fixation on a hypothesis: twisting all data in an attempt to fit it)
• Premature closure of hypothesis generation
• Rule-out syndrome: (due to poorly focused history-taking)
• Generation of very unlikely hypothesis (novelty)
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Use of time as a diagnostic aid
Wait and see approachAbout 72 % of patients who had originally been
undiagnosed did not need to return to their doctor mainly because of spontaneous remission of symptoms
The doctor must be able to control in himself and in his patient the almost inevitable feelings of uncertainty
Use safety net properly It allows doctor to have a course between the ‘over-
reaction’ and the “under-reaction”
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By using time as a diagnostic strategy, the
following problems can be avoided:• Devoting too much time to minor or self-limiting
conditions• Unnecessarily subjecting his patients to
inconvenient, painful or costly investigations• Increasing his patient’s anxiety • Referring to other specialties too frequently or
with an inappropriate degree of urgency
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