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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