By Michael Sheldon, John Brooke, Alan Rector
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Extra resources for Decision-Making in General Practice
The patient-centred practitioner knows that more than 50% of all illnesses cannot be "diagnosed" in this way. He is quite ready to reach an understanding of the illness in some other way, and this understanding can still lead to effective clinical decisions. Howie (1972) has shown how general practitioners may go from clinical observation and interpretation to treatment, without diagnosis in the conventional sense. The diagnostic label is applied post hoc, after the management decision has been made.
The four diagnoses were: pericarditis, duodenal ulcer and depression, multiple sclerosis and peripheral neuritis. In this context, all the physicians could be expected to see as their chief task the attainment of a c1inico-pathological diagnosis. In the similar study done by Smith and myself (1975) the same thing applies in two of the cases. In the third, however - a patient with depression and anaemia - differences between the two groups of physicians did begin to emerge. most significant feature of general practice is that, usually, the doctor already knows the patient.
Any experiment wh ich controls the context is bound to iron out any difference that arises from the context. Although Gale and Marsden (1985) do not use the term "mental set" 1 think their "memory structure" is elose to it. They see m to be saying the same thing, ie. that what a elinician perceives, how he formulates a problem - the hypotheses he makes - are determined by his mental set, memory structure, world view. The elinicians in their study seem to me to be working at the "doctor-centred" end of the continuum.