Monthly Archives: November 2017

and the presenting problem is……

Textbooks in various specialties often tend to group problems pathologically or by some other logical system. Thus a dermatology text may have a contents page with chapter headings on infections and infestations, bullous diseases or vascular disorders and so forth.  Internal medicine will divide itself into systems and musculoskeletal and orthopaedic problems may be organised according to anatomy or causes such as trauma, inflammation, degeneration etc.  This is useful as it helps systematise and broaden our knowledge and directs our thinking to causes and management for particular diagnoses.  Sometimes curricula are framed in this sort of way.

However, general practice patients don’t always present with a specific diagnosis at the ready and management cannot always be restricted accordingly. This is why trainees often prefer to learn with case-based discussion and why Murtagh’s General Practice has been so useful with many of its chapters based on commonly presenting symptoms. Similarly in Problem-Based Learning even the learning of basic physiology and anatomy is stimulated by the problem presented by the patient.  It is helpful for learning to be based in the real world but the educator’s challenge is to then ensure that the learner is also made aware of the broader context of the curriculum in its entirety.

The last post was about teaching in the musculoskeletal medicine area. The presenting problem may be a sore shoulder – but turn out to be cardiac pain or polymyalgia rheumatica rather than adhesive capsulitis or rotator cuff injury. The presenting problem may be a sore foot but turn out to be a plantar wart or tinea rather than a Morton’s neuroma or gout, thus drawing in the broad area of dermatology.  And all these possibilities are relevant to the trainee GP.  With cases it is possible to explore other important factors in general practice and to emphasise the importance of patient-centredness, the biopsychosocial perspective and whole person care.  

Perhaps a pain has become more significant because of other things happening in the patient’s life and functional deficits may become more crucial if the patient is also a carer or becomes unable to do their job.  There may be a cure for a particular problem within a limited time frame – or the condition may be chronic, requiring ongoing care and support where the doctor patient relationship is crucial and this should be articulated. It may even be possible to include concepts such as coping with uncertainty.  The presenting problem can be a window onto much more.

At the end of a successful educational session (in its broadest definition) the outcome could be expected to include increased confidence, increased skills (competencies), and their implementation in practice – but also an increased understanding of the uniqueness of the general practice context and its possibilities and limitations.

Don’t let learning be limited to a dot point in a curriculum document!  There are broader horizons.