Symptoms, reasons for encounter and diagnoses. Family practice is an international discipline

Abstract

‘There is no disease, respecting which it can be said that the symptoms which mark its very outset and its course, the symptoms which mark its decline, the symptoms which enable us to tell at the outset what will be its course, the effects which follow after the disease has apparently ended and the influence which pre-existing conditions of health and disease as well as that which drugs and other therapeutic agents exert on its progress, termination and sequelae are perfectly known’ (Jenner 1875). For the organization of primary health care and family practice to be optimal, it is necessary to know whom we are seeing and why they see us. The average number of consultations per family physician is 5.3 per year and patients may present three to four symptoms per consultation. Frequently, the consultation cannot be encapsulated in one diagnostic code and requires several discreet symptoms at that time without a diagnostic or any other label. Soler has gathered together data from three very distinct countries, Malta, Netherlands and Serbia, looking at precisely this aspect of the consultation. He has systematically collected data on the patient’s ‘reason for encounter’ (RfE) and structured data in the form of ‘episodes of care’ (EoCs). An EoC is defined as a health problem from its first presentation by the patient until the completion of the last encounter for it. It may be modified over time. The data for the three papers come from 69 doctors who between them recorded data over the period of 1 year in Serbia to 11 years in the Netherlands. The first paper is a study of the epidemiology of family medicine in these populations. Incidence and prevalence rates, especially of RfEs and episode labels, are compared. The second paper focuses on diagnosis and how the reason for the encounter has a predictive quantifiable probability for the eventual diagnosis for that EoC. What is remarkable is that here again is proof of the family physicians diagnostic volume. The data presented in this study confirm the fact that a family doctor makes between 1000 and 4000 diagnoses per year first described by Hodgkins. This paper also demonstrates the association between symptoms and diagnoses in primary care. Headache for example has a positive odds ratio for sinusitis. This does not mean that the two are causally linked but is more a reflection of the frequency with which we see sinusitis in primary care. The third paper really illustrates something extraordinary. Independent of country, the relationship between RfE and the eventual diagnostic term used to describe that EoC is very similar albeit with the limitations of fairly wide confidence intervals and only four EoC. Nevertheless, it looks like primary care predictors of diagnosis seem to be relatively independent of country in this study. For the first time, we start to see the development of pre-test probabilities of symptoms for diseases in primary care. This collection of papers are not purely a set of epidemiological descriptions and the fourth starts to explore the wider implications. The authors take a line of reasoning that medically unexplained symptoms as a term is arrogant and doctor centred point of view based largely on a biomedical model rather biopsychosocial. It is unlikely that all elements of the consultation are, or could be, recorded in a consultation and there is a lack of disclosure of symptoms by patients with up to a third not being expressed. Misunderstandings are another common problem seen within the consultation process. Even the use of RfE will not capture all that worries the patient and opens the door for using other systems in parallel to the consultation such as the ability for the patient to enter symptoms directly into the electronic medical record. This set of papers is successful at illustrating a system that captures the primary care RfE and sheds light on the process leading to the labelling of the EoC. Naturally, there is much more work but Soler using International Classification of. Primary Care has shown a way that we can investigate more thoroughly the critical role and process of the family doctor as the primary diagnostician. This in itself opens up a completely new area of research looking at the prognostic and therapeutic approaches using the RfE and EoC approach.