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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
[email protected]
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
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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:
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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 Levenstein’s patient centered clinical method
principles
– Discuss the diagnostic process
• Method: interactice presentation, 15 minutes
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Levenstein’s model (1984)
1. Evaluating both the disease and the illness
experience
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Differential diagnosis
Extent of disease
(effect on the feelings, expectations, ideas and
functions of the patient)
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Disease
Illness
“Differentiated”
“Unique personal experience”
• Signs and symptoms
• Feelings
• Abnormal tests
• Expectations
• A “classification”
• Fuctions…
• Illness is a personal perception
Doctor waves back and forth
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Example: increased cholesterol
• Disease
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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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2. Understanding the whole person
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“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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3. Finding common ground with the patient
about the problem and its management
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Problems and priorities
Treatment goals
Roles of doctor and patient in the treatment
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4. Incorporating prevention and health
promotion
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Health promotion
Risk reduction
Early diagnosis
Decreasing complications
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5. Enhancing the doctor-patient relationship
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Features of the therapeutic relationship
Sharing of power
Care and cure
Self awareness
Transference and countertransference
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6. Being realistic
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Time
Resources
Team
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The diagnostic process
Clues
Hypothesis
Review
Unexpected clues
Investigation
Finding commmon ground
Management decision
Follow up
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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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