Saudi Diploma in Family Medicine

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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 zekeriya.akturk_at_
gmail.com www.aile.net
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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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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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• 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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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 Levensteins patient centered clinical
  method principles
• Discuss the diagnostic process
• Method interactice presentation, 15 minutes

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Levensteins 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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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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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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• 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
Person
Illness
Environment
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• 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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• Incorporating prevention and health promotion
• Health promotion
• Risk reduction
• Early diagnosis
• Decreasing complications

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• 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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• Being realistic
• Time
• Resources
• Team

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The diagnostic process
Clues
Hypothesis
Unexpected clues
Review
Investigation
Finding commmon ground
Management decision
Follow up
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Clue nocturnal dyspnea
Hypothesis cardiac asthma
No
Hypothesis organic disease leading to sleep
disorder
Clue abdominal discomfort, 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
Yes
Clue cancer history
Hypothesis cancer and op. anxiety