Transcript GP_4001_Lecture_1

GP 4001 Lecture Series
2007-2008
1. Introduction
What I plan to cover today
• Learning outcomes for the course
• Evaluation and assessment of this
course
• How general practice differs from
hospital medicine
• Nature and scope of general practice
Learning Outcomes for this
course - I
• Develop a rapport with patients such that
patients are at ease in discussing their health
problem(s) (comm)
• Gather appropriate information on the
patient’s health problem(s) including
information on the patient’s own perspective
on the problem(s). (udp, comm)
• Generate a reasonable range of diagnostic
possibilities for undifferentiated medical
problems presented by patients (udp)
• Investigate these diagnostic possibilities
using appropriately focused history taking
and selective physical examination (udp,
comm)
Learning Outcomes for this
course - II
• Construct a general model for the safe and
effective management of patients with
multiple and long term health problems
(cdm)
• Adapt this model to the long term health
problems commonly encountered by doctors
(cdm)
• Construct an appropriate and feasible
management plan to deal with the physical,
psychological and social aspects of patient’s
problem(s) (udp, cdm)
• Negotiate this plan with the patient. (comm)
Learning Outcomes – three
principal domains
• Dealing with undifferentiated problems
presented by patients (udp)
• Management of chronic ill health (cdm)
• Communication (comm)
Assessment and Evaluation
• Assessment
• End of year exam – MEQ format
• GP attachment assessment by GP tutor
• Diagnostic thinking
• Patient management
• Attitudes to patients and staff
• Responsiveness to teaching and enthusiasm for learning
• Evaluation
• Will be asked to complete an on-line evaluation by
MarkClass
• In class evaluation exercises throughout the year
How general practice differs from hospital
medicine I - the nature of illness seen
• General Practice
• non-illness &
disorganised illness
• acute self-limiting
• chronic stable
• all age groups
• mixed physical,
psychological and
social
• Hospital
• nearly all clear cut
disease
• acute life threatening
• acute-on-chronic
• categorised by age
• physical and
psychologial divided virtually no social
GP v Hospital morbidity
by selected ICD categories I
ICD Heading
GP
Hospital
Infections
Neoplasms
Mental disorders
Cardiovascular
Respiratory
Digestive
4%
1%
10%
8%
19%
4%
2%
8%
4%
9%
8%
10%
GP v Hospital morbidity
by selected ICD categories II
ICD Heading
GP
Hospital
Genito-urinary
Childbirth & pregnancy
Skin conditions
Musculo-skeletal
Symptoms & ill-defined
conditions
Accidents
5%
10%
6%
7%
8%
8%
19%
2%
3%
6%
5%
10%
Spectrum of morbidity
in General Practice
15%
Minor
Intermediate
Major
53%
32%
Bio-psycho-social diagnosis
(a.k.a. ‘tri-axial diagnosis’)
• Diagnosis in
• physical
• psychological
• and social terms
• Note - not either/ or but degrees of each
• A manifestation of ‘holistic’ medicine non-reductionist
• Philosophically breaking down Cartesian
dualism - the ‘mind-body split’
Common problems seen in
general practice - Physical
• Respiratory tract - colds, flu, asthma,
bronchitis
• Gastro-intestinal tract - D&V, gastroenteritis,
peptic ulcer, irritable bowel
• Cardiovascular - IHD, hypertension
• Musculoskeletal - backache, OA, soft tissue
• Endocrine - diabetes, thyroid disease
• Genito-urinary - cystitis, STDs
Common problems seen in
general practice - Psychological
• Adjustment reactions e.g. grief reaction
• Anxiety
• Depression
• Mixed anxiety-depression
• Drug and alcohol problems
• Chronic stable schizophrenia
• Post-traumatic stress disorder
Common problems seen in
general practice -Social
• Relationship difficulties
• Job dissatisfaction
• Effects of poor housing
• Effects of unemployment/ social
deprivation
• Lack of education
How general practice differs from
hospital medicine II - Organisation
• General Practice
• small units, noninstitutional
• non-hierarchical
teams
• low tech
• easily accessible
• Hospital
• large institutional
units
• highly
hierarchical teams
• high tech
• filtered access
Levels of care
location of care
Regional Hospital
General hospital
General practitioner
Self care
People looked after
1,000,000
20,000
2,000
5
The illness ice-berg
MAJOR ILLNESS
MINOR ILLNESS
SELF-CARE
PRE-SYMPTOMATIC DISEASE
HEALTH
The ‘gate-keeper function’
• Controls access to more expensive
secondary care resources
• Necessary (essential) for costcontainment
• Appropriate specialist selected for
patients who need one
• Avoidance of hazards of specialist care
for patients who don’t need it
• Maintenance of skills of specialists
The ‘amoeba’ that is
general practice (after Metcalfe, David)
SOCIETY
PRIMARY
CARE
HOSPITAL
•ageing
Capital intensive
Low capital
•increasing chronic
morbidity
Labour intentsive
Lean manpower
•declining family ties
•changing attitudes to
NonHierarchical
professionals
hierarchical
•polico-economic
change
Stiff interface
•ecological change
Fluid interface
Recommended Textbooks
• Pocket Essentials of General Practice by
Colin Bradley Saunders/ Elsevier
ISBN 13-978-0-7020-2648-5
• A Textbook of Family Medicine by Ian
R. McWhinney Pub Oxford Medical
ISBN 0-19-515518-X
• General Practice by John Murtagh
McGraw-Hill Education
ISBN: 0074711776