“The central tasks of a physician’s life are understanding illness and understanding people. Because one cannot fully understand an illness without also understanding the person who is ill, these two tasks are indivisible.”…McWhinney in Family Medicine
In the Human Centered Health Home (HCHH), we’ve identified a process that allows for exploration and training of participants (humans acting as patient and doctor and other roles). The elements of the process are Respecting, Connecting, Protecting, Detecting, Correcting and Reflecting. Other blog posts have introduced and explored the first three. We’ll focus on Detecting in this post.
What are we detecting and how do we do it? It starts with the patient's chief complaint (CC) or current illness. We’re looking for alignment or misalignment with the patient’s self-defined life goals including physical, intellectual, emotional and spiritual aspects, as needed. Context is important, too, to “understand the person who is ill”, including the patients living, learning and working worlds. The past medical, family, and social history of the patient forms part of the context considered in the clinical encounter. Information about chronic diseases, past hospitalizations, allergies to medications or environmental sensitivities, current medications and nutraceutical use, immunizations and transfusions are located in the medical record by the end of the first or second visit with a physician.
As we understand what the patient isn’t able to be, do or have as a result of their current illness, we clarify how that deficiency defines their goal. The deficiency also helps both patient and physician to define the meaning of the illness. We may even engage the patient after exploring their situation with a goal statement that starts with their deficiency and their feeling about it, if necessary. “You’re feeling ________ because you cannot _________, and you would like to be able to___________. The goal statement helps the patient move toward resolution, as possible, after engaging the physician with their context and value beliefs.
“You’re feeling worried about your inability to grip the handle of the cooking utensils, threatening loss of your job as a cook and you’d like to get rid of the weakness in your grip before Tuesday when you have to go back to work in Shorty’s Bar and Grill.” That sort of statement personalizes the deficit and the goal and gives insight into possible meaning of the illness or injury. It also pre-identifies the outcome goal and let's us know when we've succeeded.
“You’re pleased that your grip is weak, preventing your use of a spatula until next week so you can get home for the holiday weekend and get engaged to your girlfriend.” Different contexts and goals arise uniquely for each unique individual. Note that the patient may have goals other than what the clinician may suspect, i.e. not wanting to work or not wanting to play in the big game, etc.
As a result of the above exploration, the physician (and the patient, but maybe with different perspectives) develops a differential diagnosis, listing mentally or in print the potential diagnoses that relate to the chief complaint of the patient. I tend to us a pneumonic SPIT standing for Serious, Probable, Interesting, Treatable, reminding me of four major categories of possible diagnoses.
What is serious that could be causing the weakened grip strength of the patient mentioned above? Stroke, Herniated intervertebral disc in the cervical spine, malignancy of the spinal cord may be considered among hundreds of other possibilities. What is probable, meaning common in my practice for persons with the same symptoms in the age group of the patient. Overuse syndrome, carpal tunnel syndrome are two possibilities. What is interesting, meaning what is the patients theory as to cause of the chief complaint. I ask the patient and assembled relatives, if indicated, "What do you think is happening to cause this?" Their theory is the most important one we're pondering. If they are right, it's wonderful, indicating good self knowledge and insight. They might say carpal tunnel syndrome or what they don't want to have, "I'm worried that it might be multiple sclerosis like my mother had." Lastly, treatable implies something we can treat and resolve or control, correlating with our mutual experience. This might again drive us to think of overuse syndrome or carpal tunnel syndrome (mild, early).
Other models of diagnostic thinking used by family physicians include the biopsychosocial model, the principles of family medicine and the natural history of disease. All of the interactions, both subjective and objective are recorded in a SOAP note (Subjective, Objective, Assessment and Plan) in the medical record, helping to better focus the patients and physicians as to the deficiency and the goal desired by treating it, if indicated. We'll expound in other blog posts about these.