1 Undifferentiated Problems in Family Medicine Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box – Riyadh Tel: – Fax:

2 Twenty AIDS Counseling Centers Gigerenzer, Hoffrage & Ebert, 1998, AIDS CARE Client: If one is not infected with HIV, is it possible to have a positive test result?

3 Twenty AIDS Counseling Centers Doctor: –"No, certainly not“ –"Absolutely impossible“ –"False positives never happen“ –"With absolute certainty, no“ –“Certainty, no” –"No, absolutely not“ –"Never“ –"Absolutely impossible“ –"With absolute certainty, no“ –"The test is absolutely certain“ Gigerenzer, Hoffrage & Ebert, 1998, AIDS CARE –"No, only in France, not here“ –"Definitely not" … "extremely rare“ –"Absolutely not" … "99.7% specificity“ –"Absolutely not" … "99.9% specificity“ –“More than 99% specificity“ –“More than 99.9% specificity“ –"99.9% specificity“ –“Don‘t worry, trust me"

4 Objectives Objectives: –be able to define undifferentiated problems (uncertainty) –be able to describe disease presentation types in family practice –be able to explain the roles of complexity, uncertainty and probability in decisions –accept uncertainty in clinical practice

5 With regard to a definition A family physician is the physician generalist who takes professional responsibility for the comprehensive care of unselected patients with undifferentiated problems, committed to the person regardless of age, gender, illness, organ system affected, or methods used. Phillips WR, Haynes DG. The domain of family practice: scope, role, and function. Fam Med 2001;33(4):273-7

6 Two sides of the story 1.Patients coming to family practice have problems, which can not be differentiated due to several reasons 2.Problems can be differentiated and diagnosed with proper methods but the GP fails to do this (malpractice?)

7 Undifferentiated problems An important proportion of patients seen in family practice have undifferentiated health problems: –%25-50 Skilled family physicians can manage these situations. McWhinney 1989

8 Why undifferentiated ? Problems may be at an early phase –Four year old boy coming with running nose and fever. After two days he may present with skin eruptions May not differentiate at al –Multiple sclerosis Not enough diagnostic facilities –Acute abdominal pain: peptic ulcer, appendicitis, renal stones, pancreatitis…? Problem may have become patients personality –Chronic headache: patients learn to live with it

Undifferentiated problems may lead to uncertainty Reasons for uncertainty –Incomplete or imperfect mastery of available –knowledge. –Limitations of current medical knowledge. –Difficulty in distinguishing between personal lack of knowledge and limitations of present medical knowledge. 9 FOX RC, 1957

10 Reasons for missed diagnoses Knowledge limitations Incomplete mastery of knowledge Incomplete evidence Poor documentation Failure of communication Inappropriate follow-up Technical errors Tejal K. Et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Annals of Internal Medicine. 2006;145(7):

11 Missed or delayed diagnoses Tejal K. Et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Annals of Internal Medicine. 2006;145(7):

12 Example Breast cancer prevalence at the age of 45: 0.4% Mammography: Sensitivity 90%, Specifity 95% 5000 Women screened for Breast Cancer (BC) 20 have BC cancer 18 correct positive 2 false negative (missed) don’t have BC correct negative 249 false positive

13 a more open doctor-patient relationship, understanding the patient's reason for attending the office, a thorough assessment of the problem, a commitment to reassessment and appropriate consultation. Strategies to manage uncertainty Biehn, J, CMAJ, 1982

14 … in this world there is nothing certain but death and taxes. Benjamin Franklin