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The general practitioner (or family doctor) is the first point of contact for any medical issue or health concern a patient might have. Whether the patient is a teenager, parent, adult, or senior citizen; whether the issue is a simple cold, a wound, or an acute or chronic disease, the wide range of people and concerns makes the job special and challenging.
The Patient-Physician Relationship
A long-term healthcare relationship between physician and patient is especially important for the general practitioner. Although medical specialists also can have long-term relationships with their patients, their contact focuses mainly on certain problems. Being a general practitioner involves collecting data related to health problems, diagnosing, creating plans for treatment and cure, and providing support. For many people, the general practitioner is the go-to doctor for any type of health problem, and family members often consult the same practice.
This makes for a comprehensive patient-physician relationship, which encompasses both medical and biopsychosocial aspects. Biopsychosocial refers to the interaction between body and mind within a social context. The social context becomes apparent through a patient’s descriptions about his or her life, as well as through indirect anamnesis by information and impressions of family members.
An interview or interaction between a patient and a physician establishes the foundation of a patient-physician relationship. During such interaction, a patient is able to express his or her concerns about health and biological and psychological quality of life, and the physician earns the patient’s trust and satisfaction by actively participating in the interaction and then delivering medical care.
For a holistic approach to health care, general practitioners usually work closely with other (specialized) physicians and healthcare professionals. An interdisciplinary approach involves a team of physicians and healthcare professionals who work together to assess a patient, make a diagnosis, plan medical and/or surgical interventions, set goals, and create a care plan. A general practitioner should introduce himself or herself personally or by phone to other professionals involved in a patient’s care.
General practitioners often cooperate with the following disciplines:
- Physical therapists
- Occupational therapists
- Speech therapists
- Home care nursing services/welfare centers
- Mental health counseling services
- Support groups
- Emergency services
Although 80% of medical issues are managed directly by general practitioners, referrals to specialists are an important responsibility. Referrals to specialized colleagues include contracted services (e.g., radiography, lab tests), consultative examinations (e.g., for special diagnostic procedures such as endoscopy for reflux), or continued treatment (e.g., to a rheumatologist in a case of ankylosing spondylitis).
Anamnesis in General Medicine
Anamnesis occurs during the first contact with a patient. The process is problem-oriented and limited to aspects necessary for successful treatment. Anamnesis is basically the medical history of the patient, which must be explored thoroughly if a general practitioner is to provide effective treatment for health-related problems. Anamnesis involves a structured set of questions about a patient’s personal and family history that may be relevant to the present problem. The practitioner should ask open-ended questions, exploring:
- Type and duration of symptoms
- First occurrence (time and circumstances)
- Pain, including type and intensity
- Previous diagnoses and treatments
- Impressions, worries, and fears of the patient
- Occupational and/or family-related stress
If treatment is required, the practitioner should obtain additional basic information during anamnesis in order to provide the best possible care.
- Known preexisting conditions (e.g. diabetes mellitus, high blood pressure, epilepsy)
- Allergies (especially to medications) and sensitivities
- Alcohol, nicotine, or drug abuse
- Pregnancy in women
- Similar conditions in the patient’s family
In German medicine, the term “erlebte Anamnese” (“lived” anamnesis; in other words, participating, being involved) refers to a quality of general practice: In the course of the patient care relationship, the physician gains a comprehensive picture of the patient’s life, including social and health conditions.
Repeated contacts during consultations, health checkups and preventive examinations, occasional house calls, and the treatment of family members complete the picture of the patient and his or her living circumstances, including extensive family and social history. A physician documents over the course of time a wide swath of relevant information.
A comprehensive understanding of a patient provides a general practitioner with a firm foundation for any counseling or treatment decisions, especially with regard to mental problems (e.g., due to personal calamities, chronic disease) and general preventive actions. It also involves active participation by the patient and the physician to achieve goals of health. Therefore, “lived” anamnesis is an important task for general practitioners.
Decision-Making Rules in General Practice
Temporizing inaction and avoiding dangerous progression
In general practice, a physician is confronted with a very broad spectrum of clinical presentations and patient information. Clear diagnoses sometimes cannot be made, and diseases often are self-limited (e.g., common cold, simple diarrhea). Out of a number of “harmless” cases, those that require immediate diagnosis and treatment must be detected (so-called red flags). At the same time, it is important to not cause more harm than benefit through diagnosis and treatment. Thus, an important principle in general practice is temporizing/observing inaction while avoiding dangerous progression.
There are two important aspects of decision-making in general practice: generalization and individualization. With generalization, the physician places the patient’s health issue in a diagnostic category. With individualization, the physician makes an assessment of the particular patient and his or her behavior.
To responsibly apply both generalization and individualization, a physician must perform thorough anamnesis and physical examination so as not to miss any significant issues (e.g., appendicitis during a gastric flu epidemic). If dangerous progression of a disease is unlikely, the physician may forgo further diagnostics and choose the strategy of temporizing/observing inaction.
An important aspect of temporizing/observing inaction is establishing feedback opportunities by either setting a follow-up appointment with a patient (“I would like to see you again in one week.”) or setting a time limit (“Please come see me if the fever has not subsided in three days.”). The strategies enable a physician to observe the progression of the disease and to react to new symptoms or aggravations.
Double hierarchization regarding frequency (prevalence) and urgency helps a physician with decision-making.
Which disease is the most frequent cause for certain symptoms and therefore most likely? Which diagnostic measures should be taken most urgently to avoid dangerous progression? For example, in a 60-year-old patient presenting with sudden onset of radiating chest pain, an electrocardiogram must be performed to exclude possible myocardial infarction.
With regard to treatment, a physician may have to decide which symptoms are most urgent, particularly if simultaneous treatment of all symptoms at once is not possible. Such decisions involve relieving the most distressing symptoms and improving quality of life.
If a patient is physically not able to go to a physician’s practice due to medical reasons or limited mobility, a house call may be necessary. House calls can be agreed-upon appointments or emergency calls. For a family physician, a house call can provide valuable insights into a patient’s living situation and environment, contributing to “lived” anamnesis.