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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

I.Inductive Reasoning method (contd)


1.
2.

Doctor-centered
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.

oh heres the
problem !

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 contd.
a)
b)

c)
d)

Undifferentiated nature of the presenting


problem.
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
Pushes the physician to ask questions and not
listen actively to his patient.
May be suitable in hospitals, but not in family
medicine.

A. Problem Solving contd


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.

Presenting
Clues

Existing
clues

PROVISIONAL DIAGNOSIS

Stage II
Hypothesis
formulation

Clinical evaluation
(history & physical
examination)
(further clues supplied or
sought)
Support

Stage III
Hypothesis
testing

Hypothesis
revision
No support

hypothesis

CRAPRIOP
(further clues
supplied or sought)

No support

Stage I
Data
collection

Outcome

Fig.1: Model of hypothetical deductive method for problem

Stage IV
Diagnosis/Pr
oblem
definition
Stage V
Managemen
t
Stage VI
Outcome
Evaluation

Stage I. Data collection & analysis


of presenting & existing clues

Sources of clues;
1. The patient
2. 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 diagnosis
4. Select diagnostic tests on two bases
a) Specificity & sensitivity
b) 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-psychosocial problem/diagnosis.

Stage V. Management
Options
Manage your patient (not the disease) by using the
CRAPRIOP acronym as follows;
C: clarify
R: reassure
A: advise the patient
P: prescribe
R: refer
I : investigate
O: observe
P : 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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