The patient-centred clinical method. 1. A model for the doctor-patient interaction in family medicine.

This article describes a patient-centred clinical method appropriate for family medicine. The method is designed to attain an understanding of the patient as well as his disease. This two-fold task is described in terms of two agendas: the physician's and the patient's. The key to an understanding of the patient's agenda is the physician's receptivity to cues offered by the patient, and behaviour which encourages him to express his expectations, feelings and fears. The physician's agenda is the explanation of the patient's illness in terms of a taxonomy of disease. In the patient-centred clinical method, both agendas are addressed by the physician and any conflict between them dealt with by negotiation. This is contrasted with the disease-centred method in which only the doctor's agenda is addressed. Further articles will describe the patient-centred method in operational terms.

How family physicians approach ethical problems.

The defining features of family medicine as described in the literature have important ethical implications. In an attempt to study the day-to-day practice of family physicians regarding these ethical issues, a 28-item questionnaire was sent to 95 part-time and 17 full-time family physician teachers associated with the University of Western Ontario's Department of Family Medicine. Of the 112 questionnaires mailed out, 97 were returned for a response rate of 86.6 percent. There was a significant spread of answers, suggesting there is no uniform opinion in the sample population. The findings suggest that there are important differences between the description of family medicine in the literature and what the family physicians in this study do in their day-to-day practice. The family physicians in this study, while prepared to coerce patients, were not prepared to discharge from their practices patients who were noncompliant. Physician age is an important variable in some ethical decisions, but not in others.

Patient-centred care: the family practice model.

The core experience of family practice-the consultation between doctor and patient-is the same for all family physicians, whether they practice in urban, rural or isolated areas. There is not yet a family practice model of this consultation, and the result is wide differences in residency programs' curricula, and residents' perception that their teachers contradict each other. This paper proposes that residents be taught, and practicing family physicians use, a patient-centred method of consultation in which the physician attempts to understand how the patient interprets his illness, as well as to establish the relationship between illness and organic pathology. Two case histories illustrate how this can be done by using open-ended questions and facilitating remarks that encourage the patient to express his feelings.

Illness Following MMR Immunization in Indian and Non-Indian Children.

A cohort study was undertaken to see if the frequency of office reported illness during the three weeks after MMR immunization was greater among Indian children (N=127) compared to non-Indian children (N=81) attending a family practice centre. All children had been given HPV(77)DE(5) vaccine or RA 27/3 vaccine between ages 11 and 24 months. Illness after immunization was not related to frequency of attendance at the medical centre or weight at age 12 months. The overall illness rate for Indian children was almost twice the rate for non-Indians. Indian children who were ill before immunization were more likely to be ill during the three week post-MMR period. No such relationship was noted among non-Indian children. This suggests that children with an established record of frequent illness are likely to experience an illness following MMR immunization. These results need to be confirmed by a prospective study.

Sex and the mentally retarded: is sterilization the answer?

The sexuality of the mentally handicapped concerns them, their parents, their family physicians and other health professionals. Parents need advice, and the well-informed family physician who has the family's trust is in a good position to give it. However, the physician must protect the rights and autonomy of the mentally handicapped patient concerning contraception, surgical sterilization and hysterectomy. Before recommending a method of contraception, the physician must identify any medical risks and be satisfied that the patient clearly understands risks and advantages. Sterilization as a method of contraception should never be considered unless the patient chooses it; involuntary sterilization can produce serious and significant psychological damage. The physician must give a detailed explanation to make sure the patient electing to be surgically sterilized understands the procedure and has fully consented without coercion. Hysterectomy should never be used as a method of sterilization.

Well child care in family medicine part 2: immunization and nutrition.

Part 1 of this article, published last month, outlined the work of a University of Western Ontario committee in establishing criteria for the well child examination. This final section describes the committee's schedule for immunization, emphasizing that the schedule itself is far less important than the need to ensure completion of an immunization program. It also outlines the committee's findings on infant nutrition, with strategies for promotion of breast-feeding.

Well child care in family medicine: part 1: physical examination, developmental assessment and evaluation of parenting skills.

The periodic health examination of the well child offers an opportunity for examining the child, immunizing the child against infectious disease, counselling the parents about adequate nutrition and evaluating parenting skills. Part 1 of this article outlines the criteria used in physical examination and developmental assessment, and counselling on parenting. Part 2 will deal with immunization and counselling on nutrition.