1. Saudi Diploma in Family Medicine
Principles of Family Medicine
The Patient Centered Clinical Method
Saudi Diploma in Family Medicine
Center of Post Graduate Studies in Family Medicine
Presented by: Dr. Zekeriya Aktürk
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2. Scenario
An old lady comes early in the morning complaining of dyspnea. She feels better after opening the window and sitting in front. You have a busy day and she is without appointment.
What is the first diagnosis you would think of?
Physical exam: normal.
What do you think now?
PA chest X-ray: normal
Did you change the order of your differential diagnoses?
McWhinney, 1997
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3. Nex day: you invite the patient with appointment
Detailled history
Main complaint: increased bowel movements
Awaking at night and feeling suffocating
Relieves in front of the window
Intestinal symptoms present since 20 years
Insomnia recently starded
Underwent cholecystectomy years ago: symptoms remained
Mastectomy due to breast CA
What is your first differential diagnosis ?
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4. More detailed history:
Fear of CA.
Widowed since severeal years; living alone
Landlord increased the rent without notice
Feels anger with the landlord
Two children married, living away
What will be your clinical approach?
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5. Objectives
At the end of this session, the participants will have knowledge on the patient centered clinical method
Defend the importance of patient centered clinical metnod in family practice
Express Levenstein’s patient centered clinical method principles
Discuss the diagnostic process
Method: interactice presentation, 15 minutes
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6. 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)
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7. “Unique personal experience” Feelings Expectations Fuctions…
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
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8. Example: increased cholesterol
Disease
CAD, past MI
Obesity
Hypercholesterolemia
Rule out depresssion
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
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9. 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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10. Disease
Person
Illness
Environment
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11. 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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12. Incorporating prevention and health promotion
Risk reduction
Early diagnosis
Decreasing complications
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13. 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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14. Being realistic
Time
Resources
Team
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16. The diagnostic process
Clues
Hypothesis
Unexpected clues
Review
Investigation
Finding commmon ground
Management decision
Follow up
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17. Clue: nocturnal dyspnea Hypothesis: cardiac asthma No
Clue : abdominal discomfort, sleep disorder
Hypothesis : organic disease leading to sleep disorder No
Hypothesis : functional abdominal symptoms. Disease triggered by personal factors.
Clue : recent sleep problem
Hypothesis : insomnia decreased the tolerance for abdominal symptoms. Insomnia is related with personal problems
Clue : children living away
Hypothesis : personal problems with children No
Clue : landlord increased the rent
Hypothesis : main problem increase of the rent
Yes
Clue : cancer history
Hypothesis : cancer and op. anxiety
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Yes