Lampe Lisa, Shadbolt Narelle, Starcevic Vladan, Boyce Philip, Brakoulias Vlasios, Hitching Rita, Viswasam Kirupamani, Walter Garry, Malhi Gin
Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
Australas Psychiatry. 2012 Oct;20(5):374-8. doi: 10.1177/1039856212458007. Epub 2012 Sep 26.
To explore the clinical reasoning processes underpinning diagnostic and management decision-making in treating patients presenting with psychological distress in general practice.
Practising GPs were invited to attend small-group workshops in which two case histories were presented. Discussion was GP-facilitated and recorded for thematic analysis. GPs provided demographic data, completed personality and attitudinal questionnaires, and answered a series of multiple-choice questions embedded in the cases.
GPs recognize the possibility of psychiatric disorders early in the clinical reasoning process, but are cautious about applying definitive diagnoses. GPs perceive that patients may be resistant to a psychiatric diagnosis and instead emphasize the need to build rapport and explore and exclude physical comorbidities. GPs see patients with a broad spectrum of distress, illness and impairment, in whom the initial presentation of psychological symptoms is often poorly differentiated and somatically focused, requiring elucidation over time. GPs therefore adopt a longitudinal strategy for diagnosis rather than investing heavily in cross-sectional assessment.
GPs appear cognizant of possible psychiatric disorders and management strategies, but employ diagnostic strategies and decision-making processes that, in addition to experience and expertise, likely reflect key differences between the primary care and specialist practice settings.
探讨在全科医疗中，针对出现心理困扰的患者进行诊断和管理决策时所依据的临床推理过程。
邀请执业全科医生参加小组研讨会，会上展示了两个病例史。讨论由全科医生主持，并进行记录以进行主题分析。全科医生提供人口统计学数据，填写个性和态度问卷，并回答病例中包含的一系列多项选择题。
全科医生在临床推理过程早期就认识到精神疾病的可能性，但对做出明确诊断持谨慎态度。全科医生认为患者可能抗拒精神疾病诊断，而是强调建立融洽关系以及探究和排除躯体合并症的必要性。全科医生会接诊各种有困扰、疾病和损伤的患者，这些患者最初的心理症状表现往往难以区分，且以躯体症状为主，需要随着时间的推移进行阐明。因此，全科医生采用纵向诊断策略，而不是大量投入横断面评估。
全科医生似乎了解可能的精神疾病和管理策略，但所采用的诊断策略和决策过程，除了经验和专业知识外，可能还反映了基层医疗和专科医疗环境之间的关键差异。
