Clinical Approach in Family Medicine

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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Clinical Approach in

Dr. Badria El Faki

The approach and caring for patients by family

At all ages, both sexes, at many sites beside their

Clinical approach in family

Inductive Reasoning method:

The classical method which is taught in medical schools when

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)

Biomedical approach which aims to

Limitations of the Inductive

Acceptable for undergraduate level

Undifferentiated nature of the presenting

Limitations of the Inductive

Undifferentiated nature of the presenting

A. Problem Solving contd

Fig.1: Model of hypothetical deductive method for problem

Stage I. Data collection & analysis

Types of clues; can be in the form of:

Role of physician at this stage

Identify all patient problems

Identify the context of the problems

Understand the patient as a whole

Stage II. Hypothesis formulation &

Recommended to formulate 5-7 hypothesis at the

As the consultation proceeds you may not find a support

New ideas may be raised during consultation which need

During this stage you should keep taking decisions based

Stage III. Hypothesis Testing

Further information is obtained by history taking and

Stage IV. Diagnosis (problem

It is not always possible to reach a definite

Hence you have to learn how to live with

Stage VI. Outcome

physicians could check if the outcome of this

as a physician you have to take care of yourself in

Regular clinical auditing

THANK YOU V MUCH

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