Diagnostic Skills Undifferentiated Problems

The family physician must be an outstanding diagnostician. Skills in this area must be honed to perfection, because problems are usually seen in their early, undifferentiated state and without the degree of resolution that is usually present by the time patients are referred to consulting specialists. This is a unique feature of family medicine, because symptoms seen at this stage are often vague and nondescript, with signs being minimal or absent. Unlike the consulting specialist, the family physician does not evaluate the case after it has been preselected by another physician, and the diagnostic procedures used by the family physician must be selected from the entire spectrum of medicine.

At this stage of disease, there are often only subtle differences between the early symptoms of serious disease and those of self-limiting, minor ailments. To the inexperienced person, the clinical pictures may appear identical, but to the astute and experienced family physician, one symptom is more suspicious than another because of the greater probability that it signals a potentially serious illness. Diagnoses are frequently made on the basis of probability, and the likelihood that a specific disease is present frequently depends on the incidence of the disease relative to the symptom seen in the physician's community during a given time of year. Many patients will never be assigned a final, definitive diagnosis, because a presenting symptom or a complaint will resolve before a specific diagnosis can be made. Pragmatically, this is an efficient method that is less costly and achieves high patient satisfaction, even though it may be disquieting to the purist physician who believes a thorough workup and specific diagnosis always should be obtained. Similarly, family physicians are more likely to use a therapeutic trial to confirm the diagnosis.

The family physician is an expert in the rapid assessment of a problem presented for the first time. He or she evaluates its potential significance, often making a diagnosis by exclusion rather than by inclusion, after making certain the symptoms are not those of a serious problem. Once assured, some time is allowed to elapse. Time is used as an efficient diagnostic aid. Follow-up visits are scheduled at appropriate intervals to watch for subtle changes in the presenting symptoms. The physician usually identifies the symptom that has the greatest discriminatory value and watches it more closely than the others. The most significant clue to the true nature of the illness may depend on subtle changes in this key symptom. The family physician's effectiveness is often determined by his or her knack for perceiving the hidden or subtle dimensions of illness and following them closely.

The maxim that "an accurate history is the most important factor in arriving at an accurate diagnosis" is especially appropriate to family medicine, because symptoms may be the only obvious feature of an illness at the time it is presented to the family physician. Further inquiry into the nature of the symptoms, time of onset, extenuating factors, and other unique subjective features may provide the only diagnostic clues available at such an early stage.

The family physician must be a perceptive humanist, alert to early identification of new problems. Arriving at an early diagnosis may be of less importance than determining the real reason the patient came to the physician. The symptoms may be the result of a self-limiting or acute problem, but anxiety or fear may be the true precipitating factor. Although the symptom may be hoarseness that has resulted from postnasal drainage accompanying an upper respiratory tract infection, the patient may fear it is caused by a laryngeal carcinoma similar to that recently found in a friend. Clinical evaluation must rule out the possibility of laryngeal carcinoma, but the patient's fears and apprehension regarding this possibility must also be allayed.

Every physical problem has an emotional component, and although this factor is usually minimal, it can be significant. A patient's personality, fears, and anxieties play a role in every illness and are important factors in primary care.

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