The Clinical Method in Family Medicine

1. The Clinical Method in Family Medicine Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847

2. 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

3. What are the methods physician used to solve problems? McWhinney, 1997

4. 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.

5. Algorithms • Clinical reasoning that proceeds systematically through branching decision points

6. Algorithms

7. Inductive reasoning methods • Chief Complaint • History of The Present Complaint • Past Medical History • Family History • Personal & Social History Drug & Allergy History Systems Review Physical Examination Biological Diagnosis Disease Management: Investigation Prescribing Follow-up Appoint

8. Doctors – centered (concentrate on doctors –agenda) • Biomedical approach (aims to diagnose or exclude organic disease • Managing a specific disease • What else?

9. Hypothetical deductive reasoning method

10. 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).

11. 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.

12. 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.

13. The diagnostic process Clues Hypothesis Unexpected clues Review Investigation Finding commmon ground Management decision Follow up

14. 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%

15. 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)

16. How can we apply this methodin family practice?

17. Levenstein’s model,McWhinney1984 The Disease - Illness Model Patient Presents Problem (s) Gathering Information Parallel search of two frameworks Disease Framework The Doctors Agenda Symptoms Signs Investigations Pathology Illness Framework The Patients Agenda Ideas Concerns Expectations Feelings Thoughts Effects Differential Diagnosis Understanding the patient’s unique experience of their problem(s) Integrating the two frameworks Explanation & planning Reaching a shared understanding & decision-making

18. Levenstein’s model (1984) • Evaluating both the disease and the illness experience • Differential diagnosis • Extent of disease (effect on the feelings, expectations, ideas and functions of the patient)

19. 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

20. Example: increased cholesterol • 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 • Disease • CAD, past MI • Obesity • Hypercholesterolemia • Rule out depresssion

21. Understanding the whole person • “as a person” (life story, personal and developmental conditions) • Context (anybody being effected from the patients condition, physical environment)

22. Disease Person Illness Environment

23. 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

24. Incorporating prevention and health promotion • Health promotion • Risk reduction • Early diagnosis • Decreasing complications

25. Enhancing the doctor-patient relationship • Features of the therapeutic relationship • Sharing of power • Care and cure • Self awareness • Transference and countertransference

26. Being realistic • Time • Resources • Team

28. 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.

29. 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?

30. 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?

31. 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?

32. 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)

33. Use of time as a diagnostic aid • Wait and see approach • About 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”

34. 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

35. It is the quality of thinking and not the quantity of facts that is likely to lead to the resolution of clinical problem