Family Medicine Activist: SPIT Out Better Diagnoses

As patients tell their story that relates to their main concern during a problem oriented office visit in Family Medicine, the Family Physician develops a list of probable causes for the problem(s).  This is called a differential diagnosis, an essential element of "physicianing".  There are many ways that physicians analyze patient information to hone in on the differential diagnosis, while simultaneously seeking to identify THE most accurate diagnosis and its cause(s).

To expand my development of the differential diagnosis, I use several models, the simplest of which is the SPIT model.  I ask myself, "What is Serious that can cause this situation (of patient symptoms and signs as relayed through their story and our physical examination)?  What is Probable (most likely given the context and our understanding of the risks in their unique circumstances)?  What is Interesting (an unusual or novel cause or the patient's/their family's theory of causation)?  What is Treatable that could be the cause(s)?

S erious
P robable
I nteresting
T reatable

For each symptom a patient had, we should be able to identify a SPIT differential diagnosis.  When I teach this to medical or nurse practitioner students, I encourage them to "SPIT" out their differential diagnosis, which gradually helps them with the speed of thinking about and refining their differential diagnosis.  I share this model with patients frequently to engage them in the process and reassure them that a lot of thinking is occurring during our interaction.

Family Medicine Activist: Keep Your Spouse and Family Doctor

Friday AM.  The sun is shining.  I'm seeing a couple together.  We're finished with relating about the three major problems of the designated patient and reviewing goals for the near future when the spouse verbally nudges the designated patient.  "Well, aren't you going to tell him?"

I knew there was something else at that moment.  It was important and possibly sensitive.  She really cared about him and kept nudging until we identified the problem and developed a treatment strategy.  It was a common problem that Family Physicians treat every day.  Somehow, he had a sub-specialty visit about the problem that had him very worried and preparing for an expensive procedure.  I sometimes get surprised at some of the expense generated in response to common problems noticed by people who "went in the wrong door." They were pleased and relieved to find it was such a simple, everyday problem, treatable with a short term prescription and a follow-up visit.

Medical care is getting complicated by electronic upgrades to our usual way of doing practice and business.  Much of it is necessary while much of it is peppered with "phony quality initiatives".  Watch out while we doctors and hospitals get "widgetized" to maximize the "suckables" for perfect billing.  Sometimes, you may need diagnostic or therapeutic interventions that are very expensive.  Other times, you may be in the wrong place for the degree of difficulty of your problem and have needless expense with no quality benefit.

Keep a relationship with your Family Physician to help you to prevent or treat conditions and diseases as you glide down a path of losing 1% of the function of your major organs each year starting at age 30.  If sub-specialty consultation is needed, your Family Physician will help you to select a physician who is aligned with your needs.  They will also advise you of what to expect and of the limits of their skills and the skills of the consultant.  This helps you to enter "the right" door and optimize health care expenditures while maintaining reasonable quality of your health (depending on random events, your health heritage, and/or your personal habits).

Sometimes it helps to have your spouse along when things are getting complicated, complex or worrisome.  You may be pleased to be reminded of your good judgement in selecting them as your spouse.

Family Medicine Activist: A Mother's Heart

 

"When the Spirit illuminates the heart, then a part of the man sees which never saw before; a part of him knows which never knew before, and that with a kind of knowing which the most acute thinker cannot imitate. He knows now in a deep and authoritative way, and what he knows needs no reasoned proof. His experience of knowing is above reason, immediate, perfectly convincing and inwardly satisfying."

A. W. Tozer (1897-1963) 

Draper's Book of Quotations for the Christian World. in WordSearch 10 software 2012

One of the great honors in Family Medicine is caring for newborn babies.  The connection between mother and baby is immediate and usually "holy".  I marvel at the heart connection and usually inquire of the new mother about how her heart is for the baby.  A knowing smile erupts, making me wonder if A.W. Tozer was referring to new mothers in the quote above.  Although Tozer was writing in an era which used the pronoun he as representing humankind, the comment is helpful for me to better describe what seems to be happening with new mothers.  They know Love.

Mothers get a huge heart for their baby.  Poets and philosophers struggle for words that can describe this whole-hearted love.  I've been blessed to witness the outward manifestations of it.  New Mothers Have Heart!

Family Medicine Activist: End of Life Discussions

Three patients over 80 years old were discussing end of life situations with me in recent months.  They, like many other seniors, are looking at their potential transition to "the hereafter".  They worry that it won't go well.  Loss of control is one of their concerns.  They have a living will and expect that it will protect them near the end of life.  Each has a daughter who knows of the living will and has health care power of attorney if my patient is incapacitated.

The Family Physician often has to introduce a discussion about the use of the living will and the DNRCC form during an appointment intended for a different purpose.  The patient does not schedule a separate appointment for this discussion, in spite of its extreme importance, ever.  There is no mechanism to be paid for the service.  We in the medical profession and patients and their families aren't yet effective enough to convince Congress to support payment for a focused visit for this purpose-advanced directives, aka end of life discussion.

Medicare includes hints about end of life discussion, but does not pay doctors for the service. "It remains legal for doctors to talk with patients during the annual Medicare visits; it's just that they can't be specifically paid for that discussion"....from Elder Law Answers web site.  So we're OK to have a very important discussion, but not able to get paid for the service, adding some frustration to intentions about end of life discussions.  

Another form they may need here in Ohio, now or later, is the Do Not Resuscitate Comfort Care form.  I like the simplicity and the list on page 2 of the form.  What do you think?  What happens in your state?

Ohio Do Not Resuscitate Forms

Family Medicine Activist: The Patient's Story

I look on the front of the patient's medical record to look at their "sign-in" form where they write the "reason for this visit".  Often, it says "to review labs" or "doctor told me to come back" and I feel disappointed that we're not connecting.  I know they can get a better experience if they enter a health goal or personal life goal such as: to have a strong enough back to pick up my grandson or to breathe well enough to visit my daughter in New Mexico this summer or to have enough stamina to finish the motorcycle repair on my Harley before my spring vacation.

The Family Physician enjoys their personal goals and the opportunity to share the challenges with the patient and their family.  We want to hear their story.  It's usually the most important thing happening in the examination room.  The physical exam supports or refutes the doctor's and patient's diagnostic hypotheses that evolve during the patient's story.  Imaging and laboratory tests, if warranted,  further clarify the probabilities associated with both patient and doctor hypotheses.  Sharing the hypotheses and the probabilities between patient and physician as they change enriches the potential for an accurate diagnosis and treatment plan- a treatment plan that will align the patient with their dream.

The patient's story is the key to goal alignment for both patient and family doctor.  It's also the key to enhancing the patient- physician relationship which grows over time, promoting better outcomes for all involved.

Keep telling your stories, Folks, we love them.