- Take an accurate and relevant history (OBSERVATION).
- Perform an accurate and relevant examination (OBSERVATION).
- Make a provisional diagnosis (HYPOTHESIS).
- Order and interpret the results of appropriate investigations (HYPOTHESIS TESTING).
- Make a definitive diagnosis (DEDUCTION).
This is the classical medical diagnostic process. “Hypothetico-deductive” thinking of the kind described here is still central to the doctor’s task in a consultation. In any single consultation the doctor may form, test and discard a large number of diagnostic hypotheses based on the information or cues he/she receives from the patient.
This is, however, a very incomplete account of the consultation.
- It is reductionist: patients are seen and treated in terms of signs, symptoms and diagnoses and labelled accordingly.
- It is doctor-centred: there is no mention of the patient’s feelings, beliefs, and opinions, any sharing of information or agreement of a management plan.
- It flounders when no objective physical disorder is unearthed.
- It does not recognise the importance of non-verbal communication.
- It omits the therapeutic use of the doctor-patient relationship.
- It fails to recognise that a consultation can be one of a series as is often the case in general practice.
- It over-emphasises the importance of decisions based on personal clinical experience: these are apt to bias because of the limited number of patients any one doctor can experience.
It is in response to these criticisms that other possibilities have developed, all broadly holistic and all perceived as more modern in approach.
The potential of each primary care consultation: (Stott & Davies 1979)
“The exceptional potential in each primary care consultation” suggests that four areas can be systematically explored each time a patient consults.
- Management of presenting problems
- Modification of help-seeking behaviours
- Management of continuing problems
- Opportunistic health promotion
But what about…