Application of Management Principles in the Management of a Patient
Reynaldo O. Joson, MD
September 3, 2006
Introduction:
Do you remember what I told you before?
Let me repeat what I said before. The concept of “management” is applicable to any situation and anything in life.
Thus, there can be management of self, management of a group of people, management of a project, and management of an organization.
There is also the management of a patient. The general principles of management are applicable to the management of a patient. In fact, I would like to tell you that if you apply the principles of management when you manage a patient, your tasks in managing a patient will be more structured and systematic and more rational.
I will show you how you can and should apply the management principles (particularly the planning function) in the management of a patient .
First, look at the diagram below that shows the essential steps in the management of a patient.
Steps in the Management of a Patient
STEPS IN THE MANAGEMENT OF A PATIENT
M.D.
|
|
v
PATIENT----------------------------------------------------------------------------------------------GOALS
|
|
|
Interview --------------------------------------|--------------------------------Physical exam
(symptoms) | (signs)
|
Clinical Diagnostic Process
| Pattern recognition
| Prevalence
|
Clinical Diagnosis ------------------------------------Advice
| |
| Paraclinical Diagnostic
| Procedure -------------------------Advice
| |
| | - Indication
| | - Selection (benefit/risk/cost/avail)
| | - Interpretation
| |
Pretreatment Diagnosis ----------------------------Advice
|
|
|
Selection of Treatment -----------------------------Advice
(Benefit/risk/cost/availability)
|
|
|
Treatment ---------------------------------------------Advice
|
|
|
Health Promotion and Maintenance ----------------------Advice
I. Overall plan in the management of a patient
A patient consults you for a health problem.
M.D.
|
|
v
PATIENT----------------------------------------------------------------------------------------------GOALS
What is your overall goal in managing this patient?
Your overall goal in the management of this patient is to resolve his health problem in such a way that you don’t end up with a dead or disabled patient nor a dissatisfied patient, and a medico-legal suit.
What are your strategies in managing this patient so that your goals are achieved?
Your strategies consist of the tasks that you have to do in resolving the patient’s health problem.
These tasks consist of the following:
Establishing rapport initially and then maintaining it throughout the course of patient management;
Formulating a clinical diagnosis followed by an advice to the patient on your findings and diagnosis;
Deciding on whether you need a paraclinical diagnostic procedure and, if you need one, selecting the most cost-effective procedure, to be followed by an informed consent on the part of the patient; if paraclinical diagnostic procedures are done, you need to interpret the results and correlate them with the clinical findings to come out with a pretreatment diagnosis, again to be followed by an advice to the patient; and lastly,
You need to decide on the most cost-effective treatment procedure for the patient.
Your tasks can be summarized by the following diagram:
Rapport
Diagnosis
Advice
Treatment Advice
What are your evaluation parameters and criteria?
You have achieved your goal in resolving the patient’s problem in such a way that he doesn’t end dead or disabled, that he is satisfied, and there is no medico-legal suit filed against you.
Criteria that you may want to use for your problem-solving and decision-making can consist of the following:
1. Rational
2. Effective
3. Efficient
4. Humane
II. Clinical Diagnosis
After establishing rapport, your initial task is to identify the patient’s problem using interview and physical examination.
Interview --------------------------------------|--------------------------------Physical exam
(symptoms) | (signs)
|
Clinical Diagnostic Process
| Pattern recognition
| Prevalence
|
Clinical Diagnosis ------------------------------------Advice
What is your goal / objective at this stage of the patient management?
To formulate a clinical diagnosis that is as specific and rational (and accurate) as possible.
What are your strategies to achieve your objective?
Interview to get symptom and other data.
Perform physical examination to get sign data.
Process the data from interview and physical examination using pattern recognition and prevalence and other diagnostic algorithm.
Formulate a primary and a secondary clinical diagnosis and quantify the degree of certainty.
What are your evaluation parameters / criteria for your clinical diagnosis?
Presence of primary and secondary clinical diagnosis with quantification of degree of certainty
Rationally arrived at using pattern recognition and prevalence processes.
Diagnostic labels as specific as possible
Exercises:
Determine the clinical diagnostic process used in the various scenarios.
A. Pattern recognition
B. Prevalence
C. Pattern recognition and prevalence
2.1 Knowing the common manifestations of 5 different diseases as follows:
Disease A - abcd (manifestations)
Disease B - fghi
Disease C - klmn
Disease D - pqrs
Disease E - uvwx
Given a patient manifesting with pqrs, your diagnosis is Disease D.
2.2 Knowing the common manifestations with its usual temporal sequence of 3 different
diseases as follows:
Disease A - a-b-c-d (manifestations)
Disease B - b-c-d-a
Disease C - a-b-d-c
Given a patient manifesting with a-b-c-d, your diagnosis is Disease A.
2.3 Knowing the common manifestations of 3 different diseases and relative frequency of each as follows:
Disease A - abcd (manifestations) Least common
Disease B - abcd
Disease C - abcd Most common
Given a patient manifesting with abcd, your diagnosis is Disease C.
2.4 Knowing the common manifestations of 3 different diseases and relative frequency of each as follows:
Disease A - abcd (manifestations) Least common
Disease B - abde
Disease C - abdf Most common
Given a patient manifesting with abcd, your diagnosis is Disease A.
2.5 Knowing the most common diagnosis of a thyroid nodule is a benign colloid adenomatous
goiter, given a patient with a thyroid nodule, you gave the abovementioned diagnosis.
III. Indications for Paraclinical Diagnostic Procedures
After formulating your primary and secondary clinical diagnoses, your next task is to determine whether you need a paraclinical diagnostic procedure or not.
Clinical Diagnosis ------------------------------------Advice
| |
| Paraclinical Diagnostic
| Procedure -------------------------Advice
| |
| | - Indication
| | - Selection (benefit/risk/cost/avail)
| | - Interpretation
| |
Pretreatment Diagnosis ----------------------------Advice
What is your goal / objective at this stage of the patient management?
To determine whether you need a paraclinical diagnostic procedure or not..
What are your strategies to achieve your objective?
Quantify the degree of certainty of your primary and secondary clinical diagnoses.
Compare the treatment plan for your primary and secondary diagnoses.
Then decide.
What is your evaluation parameter / criterion for your decision on whether a paraclinical diagnostic procedure is needed or not?
Decision rationally arrived at using the two processes mentioned above.
Exercises:
3. Determine whether a paraclinical diagnostic procedure is indicated or not in the various scenarios. Write (I) if indicated and (NI) if not indicated.
Certainty Plan of Treatment
3.1
Primary clinical diagnosis 98% Surgical
Secondary clinical diagnosis 1-2% Nonsurgical
3.2
Primary clinical diagnosis 60% Surgical
Secondary clinical diagnosis 40% Nonsurgical
3.3
Primary clinical diagnosis 60% Surgical excision
Secondary clinical diagnosis 40% Surgical excision
3.4
Primary clinical diagnosis 90% Mutilating operation
Secondary clinical diagnosis 10% Nonmutilating operation
3.5 Primary clinical diagnosis 70% Chemotherapy
Secondary clinical diagnosis 40% Radiotherapy
IV. Selection of a Paraclinical Diagnostic Procedure
After deciding there is a need for a paraclinical diagnostic procedure, your next task is to select from various alternatives or options.
Clinical Diagnosis ------------------------------------Advice
| |
| Paraclinical Diagnostic
| Procedure -------------------------Advice
| |
| | - Indication
| | - Selection (benefit/risk/cost/avail)
| | - Interpretation
| |
Pretreatment Diagnosis ----------------------------Advice
What is your goal / objective at this stage of the patient management?
To select the most cost-effective paraclinical diagnostic procedure.
What are your strategies to achieve your objective?
List down the various alternative and options.
Compare them using the parameters of benefit, risk, cost, and availability.
Decide which is the most cost-effective.
Recommend to the patient.
Get his consent.
What is your evaluation parameter / criterion for your selection of a paraclinical diagnostic procedure for your patient?
Most cost-effective procedure.
Decision arrived at using the processes and steps mentioned above.
Exercises:
4.1 Determine what paraclinical diagnostic procedure should be selected in the various scenarios.
Write your choice in term of the option number enclosed in parenthesis, like so (#).
Procedure Benefit Risk Cost (PhP) Availability
Options
4.1.1
1 most direct acceptable 1000 available
2 indirect acceptable 1500 available
3 indirect acceptable 1000 available
4.1.2
1 accuracy 95% acceptable 5000 available
2 accuracy 90% acceptable 3000 available
3 accuracy 50% acceptable 1000 available
4.2. Determine what paraclinical diagnostic procedure should be selected in the various scenarios.
Write your choice in term of the option number enclosed in parenthesis, like so (#).
Procedure Benefit Risk Cost (PhP) Availability
Options
4.2.1
1 yield greatest acceptable 4000 available
2 yield 90% acceptable 4000 available
3 yield 80% acceptable 3000 available
4.2.2
1 yield 90% acceptable 2000 available
2 yield 90% acceptable 2500 available
3 yield 95% acceptable 4000 available
V. Selection of a Treatment Procedure
After arriving to a definite pretreatment diagnosis, your next task is to decide on the treatment.
Pretreatment Diagnosis ----------------------------Advice
|
|
|
Selection of Treatment -----------------------------Advice
(Benefit/risk/cost/availability)
|
|
|
Treatment ---------------------------------------------Advice
What is your goal / objective at this stage of the patient management?
To select the most cost-effective treatment procedure.
What are your strategies to achieve your objective?
List down the various alternative and options.
Compare them using the parameters of benefit, risk, cost, and availability.
Decide which is the most cost-effective.
Recommend to the patient.
Get his consent.
What is your evaluation parameter / criterion for your selection of a treatment procedure for your patient?
Most cost-effective procedure.
Decision arrived at using the processes and steps mentioned above.
5. Determine what treatment modality should be selected in the various scenarios.
Write your choice in term of the option number enclosed in parenthesis, like so (#).
Procedure Benefit Risk Cost (PhP) Availability
5.1
1 greatest survival rate acceptable 5000 available
2 rate < 1 > 3 acceptable 4000 available
3 least survival rate(SR) acceptable 3000 available
5.2
1 SR1 = SR2 lesser 5000 available 2 SR2= SR1 more 5000 available
5.3
1 as effective as 2 acceptable 8000 available
2 as effective as 1 acceptable 4000 available
5.4
1 most effective acceptable 2000 available
2 effectivity <1 >3 acceptable 3000 available
3 least effective acceptable 4000 available
The following table shows the similarities in the basic steps in planning in different management situations commonly encountered by a physician-manager.
The following table shows the similarities in the basic steps in planning proper in different management situations commonly encountered by a physician-manager with some differences in terminology in the initial step prior to the planning proper (situational analysis, problem identification, and diagnosis).
Exercise:
Given a hypothetical patient. Answer the questions below with the objectives, strategies, and evaluation parameters in the management of patient in mind.
A 50-year-old female with a solitary right breast mass noted 4 weeks prior to consult. The mass is 3-cm in size, located at the upper outer quadrant, firm in consistency, feels solid, movable, with well-delineated border. No tenderness. No erythema. No skin retraction. No axillary lymph node. No history of previous medical treatment.
1. State your overall goals in the management of this patient.
2. Give your primary and secondary clinical diagnoses. State processes used and expound. Quantify your degree of certainty for the primary and secondary diagnoses with 90% being quite certain and the one for the primary diagnosis should always be greater (at least 60%) than that for the secondary diagnosis.
3. Decide whether a paraclinical diagnostic procedure is needed or not using at least the data from number 2. State processes used and expound if need to.
4. If a paraclinical diagnostic procedure is needed, choose from the following options: needle biopsy, mammography, ultrasound. Justify choice.
5. If the pretreatment diagnosis turns out to be a breast cancer, choose from the following alternatives or options: surgery, chemotherapy, and radiotherapy. Justify choice.
6. If the pretreatment diagnosis turns out to be a fibroadenoma, choose from the following alternatives or options: surgery, hormonal therapy, and virgin coconut oil. Justify choice.
If there is distortion of the file, see attached file.
ROJ@12sept30