Book review: Diagnosis and risk management in primary care; words that count, numbers that speak

This is a gem of a book, writes Dr Linda Miller.

This book will have wide appeal from medical students to experienced GP trainers. It is peppered with examples from years of GP experience. Rather than focus on the biases which influence our decision making, this book provides practical tools to reassess our diagnoses and communication tips to improve history taking, patient satisfaction and reduce risk.

Complexity of diagnosis

The complexity of diagnosis and the responsibility of the doctor in assigning a specific diagnosis are considered.  Biomechanical and psychosocial models and the context of the diagnosis in the individual patient’s narrative, belief system and definition of health are explored.

The role of diagnosis in communication between healthcare professionals (e.g. functional disorders) and with the patient is discussed. The secondary care model and primary care tolerance of uncertainty and use of the passage of time with more selective investigation and treatment are contrasted. The tendency for patients to perceive the former as better is acknowledged. The overriding theme is beneficence and non-maleficence. We are reminded to use investigations and treatments only when benefits outweigh harm. The exercises encourage reflection and improved practice. They would provide good supporting information for appraisal and revalidation.

Tools and exercises

Chapter two uses a discussion to explore opinions on healthcare policy and reform. Sections of the debate could be used in role-play with students to explore controversies.

The ‘Iceberg’ images put the consultation in the context of the population that do not consult. This is a reminder of the importance of the ideas, concerns and expectations that lead the patient to consult.

For those of us who are ‘statistically challenged’, introducing odds and likelihood ratios as tools adds clarity.  Chapter five condenses hours of reading into a recipe book of odds. RCGP curriculum headings make these of particular value to those studying MRCGP. These odds help us to reconsider the value attributed to specific symptoms, signs and investigations during diagnostic hypothetico-deductive reasoning.

In latter chapters, further tools include a grid, mnemonic, rhyme and ode.

Risk management, diagnostic error and patient complaints are explored. As a final exercise, critical review of a recent diagnoses is suggested.

Dr Miller is a GP, tutor and London deanery coach and mentor

  • Diagnosis and risk management in primary care; words that count, numbers that speak is by Wilfred Treasure

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