Why is this patient here today?BMJ 2005; 331 doi: http://dx.doi.org/10.1136/bmj.331.7518.678 (Published 22 September 2005) Cite this as: BMJ 2005;331:678
- Frank Sullivan, NHS Tayside professor of research and development in general practice and primary care,
- Jeremy C Wyatt, professor of health informatics
- University of Dundee.
Defining the reason for a patient's consultation may seem straightforward, but often deeper consideration is required. Information tools are less important in this phase of the consultation than other phases, but may augment the interpersonal skills of the doctor. At this early stage an open question like “How can I help you today?” and attention to non-verbal cues are more likely to be productive than launching into a closed question and answer session.
If the doctor knows Mr Evans (see box opposite), he will already have noticed the sad expression on the patient's face when he went to the waiting room to call him in to the consultation. The slow, hesitant speech with which Mr Evans talks of his headache is another item of non-verbal information indicating a possible diagnosis of depression.
Mr Evans has come to see his general practitioner (GP) because of headaches, sleep disturbance, and sexual difficulties. These problems need to be considered in detail. The symptoms are common in general practice, and most experienced doctors and nurse practitioners will have an approach to assessment with which they are comfortable. Experienced doctors use hypothetico-deductive reasoning methods when assessing patients' problems. An initial clinical feature, headache perhaps, prompts a doctor to recall an “illness script” derived from his or her experience and education that seems to explain a patient's problems. The doctor hypothesises that the diagnosis is, in this case, possibly depression, and tests this hypothesis by asking further questions, examining the patient, or doing laboratory tests to confirm or rule out the diagnosis.
Less experienced doctors may use a or, when an unusual presentation occurs, they may return to inductive reasoning learnt as an undergraduate or trainee. This more exhaustive process involves taking a complete history, …
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