Family Practice Vol. 16, No. 6, 633
© Oxford University Press 1999
Book Reviews |
A day in the office: case studies in primary care.
GP in Bristol and Special Lecturer in Primary Health Care, University of Bristol
JA Eaton and JD Cappiello (eds). (360 pages, $39.95.) Mosby, 1998. ISBN 0-8151-1559-8.
Case analysis, the discussion of patients seen recently, is a time-honoured part of medical education. I have spent many happy hours with GP registrars in our practice discussing patients that they have seen in the previous few days, chosen either at random, or because they struck the registrar as interesting or problematic. This book attempts to do a similar thing in written form.
It is written by two assistant professors in the Department of Nursing at the University of New Hampshire in the United States and is based on case studies that they have used when teaching student nurse practitioners. The level of knowledge and depth of analysis would make it appear equally applicable to GPs. A fictional 2 days of consultations are presented consisting of a mixture of normal consultations (15 minutes) and complete physical examinations (45 minutes). After reading the case scenario, you are invited to complete an assessment form of the main problems or issues you have identified, a plan and a prescription.
The first case in the book describes a 56-year-old man coming for an complete physical examination because he wants to start an exercise programme. There follows an amazingly detailed description of the history, including a review of all body systems, and physical examination. I looked in vain for risk factors but could find none. However, the next four pages suggest that I should seriously consider doing an ECG, blood cholesterol, sugar, thyroid function, before moving on to recommend colorectal cancer, prostate cancer and glaucoma screening.
Case two is a normal consultation of a 29-year-old woman complaining of painful micturition. Again, a very full history and examination (totally unrealistic for a 15-minute consultation), but the discussion section does discuss relevant issues such as what urine lab test should be done (and even acknowledges that none may be necessary) and for how many days antibiotics should be given.
This book does not travel well across the Atlantic. There is a much greater emphasis on excluding rare diagnoses, and considering extensive investigations than would be considered appropriate in the UK or in other European countries where I have observed GPs and nurses working. There is a lack of acknowledgement of the hypotheticodeductive way in which clinicians often assess problems, and that an exact diagnosis is often not appropriate in primary care. Furthermore there is an underemphasis on the way that social and psychological factors need to be looked at simultaneously with physical factors in both assessing a patient's problem and planning their care.
The thing that I missed most was that there is no discussion of what are often the most interesting questions that arise from case analysis such as "why did that patient really come to see me" and "why did that consultation go badly?"
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