Skip to main content

Main menu

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers

User menu

  • Subscriptions
  • Alerts
  • Log in

Search

  • Advanced search
British Journal of General Practice
Intended for Healthcare Professionals
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
  • Subscriptions
  • Alerts
  • Log in
  • Follow bjgp on Twitter
  • Visit bjgp on Facebook
  • Blog
  • Listen to BJGP podcast
  • Subscribe BJGP on YouTube
Intended for Healthcare Professionals
British Journal of General Practice

Advanced Search

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
The Back Pages

Book review

Wilfrid Treasure
British Journal of General Practice 2007; 57 (536): 256.
Wilfrid Treasure
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info
  • eLetters
  • PDF
Loading
Nicholas Summerton Patient-Centred Diagnosis RadcliffeOxford 2006 PB, 152 pages, £21.95, 1 84619 055 X Embedded Image

The book is well written: even the more technical sections explaining what obstacles researchers meet and how they tackle them are expressed in a straightforward language that a nonresearcher like me is able, on the whole, to understand and sympathise with. Occasionally, informality slips into lack of precision but, in general, the style is clear, flowing and engaging.

My reservations are an indication of the extent to which the book made me think. Take the title. I guess Dr Summerton had problems with it because his definition is more than 70 words and, even then, confines itself to ‘the context of a known abnormality’, whereas a lot of primary care concerns symptoms which may not signify any abnormality: the topic of medically unexplained symptoms is given only two pages in the whole book. Elsewhere Dr Summerton writes that: ‘Patient-centred diagnosis should be based on the best available scientific evidence … clinical experience is also a critical component …’. Compare this with the Cochrane website: ‘The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research’.1 Dr Summerton's diagnoses might be patient-specific but they do not have the patient-centred ‘shared understanding’ important to McWhinney.2

Let us look at some examples from the book. For cranial arteritis likelihood ratios for clinical features and ESR relate to the outcome not of blindness, which would be patient centred, but of abnormal histology. Presumably the patient-centred outcome has not been researched, but this is not acknowledged or discussed. For migraine Dr Summerton refers to McWhinney's suggestion that the name matters less than whether or not the condition is sumatriptan-sensitive — diagnosis as ‘management naming’ rather than ‘disease naming’3 — but again this idea is not developed. Elsewhere Dr Summerton writes: ‘obviously, it is always necessary to exclude organic disease when presented with a symptom of possible organic significance, such as unexplained weight loss, chest pain or palpitations’. I think being patient centred means that it is often unnecessary — and inappropriate — to do this. So a lot of the book, despite its title, has a rather biomechanical approach.

My other main reservation is that I am not sure where to start the proposed Bayesian journeys or whether I like the routes. Take cranial arteritis and migraine again. We are given the population prevalence of cranial arteritis and the prior probability of migraine in patients presenting to primary care clinicians with new onset headache. These are based on different denominators. Furthermore, negative likelihood ratios for a specific diagnosis, such as cranial arteritis, may help me reassure the patient but reassurance about cranial arteritis is of little value if the patient turns out to have migraine or trigeminal neuralgia. Likelihood ratios for ‘persisting and disabling’ or ‘needing referral’ might well be more useful: they would lead to the higher posterior probabilities in primary care that Dr Summerton hopes for. I would have liked some discussion of this, especially in the sections advising how to judge the validity of research results and where research needs to be directed in the future.

In the meantime I have learned some useful things. I had already come across the distinction between (volunteered) symptoms and (elicited) semeions.4 Dr Summerton introduces me to another useful distinction: iatrotropic symptoms are those ‘that cause a patient to consult’ and non-iatrotropic symptoms ‘those that are elicited during the course of the medical interview’. Surely they will have different likelihood ratios and I now have words — however awkward — to use when discussing this notion with checklist-laden medical students and junior doctors.

  • © British Journal of General Practice, 2007.

REFERENCES

  1. ↵
    1. Cochrane Library
    , http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/WhatAreSystematicReviews.html (accessed 29 Jan 2007).
  2. ↵
    1. Stewart M,
    2. Brown J.B.,
    3. Weston W,
    4. et al.
    (1995) Patientcentred medicine: transforming the clinical method (Sage, London).
  3. ↵
    1. Dixon A
    (1986) ‘There's a lot of it about’: clinical strategies in family practice. J R Coll Gen Pract 36:468–471.
    OpenUrlPubMed
  4. ↵
    1. Wilbush J
    (1984) Clinical information — signs, semeions and symptoms: discussion paper. J R Soc Med 77:766–773.
    OpenUrlCrossRefPubMed
Back to top
Previous ArticleNext Article

In this issue

British Journal of General Practice: 57 (536)
British Journal of General Practice
Vol. 57, Issue 536
March 2007
  • Table of Contents
  • Index by author
Download PDF
Email Article

Thank you for recommending British Journal of General Practice.

NOTE: We only request your email address so that the person to whom you are recommending the page knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Book review
(Your Name) has forwarded a page to you from British Journal of General Practice
(Your Name) thought you would like to see this page from British Journal of General Practice.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Book review
Wilfrid Treasure
British Journal of General Practice 2007; 57 (536): 256.

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Book review
Wilfrid Treasure
British Journal of General Practice 2007; 57 (536): 256.
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Mendeley logo Mendeley

Jump to section

  • Top
  • Article
    • REFERENCES
  • Info
  • eLetters
  • PDF

More in this TOC Section

The Back Pages

  • Evidence-based medicine and Web 2.0: friend or foe?
  • Tips for GP trainees working in obstetrics and gynaecology
  • How to protect general practice from child protection
Show more The Back Pages

Book review

  • Ice bird: the classic story of the first single-handed voyage to Antarctica
  • Book Review: Here Comes Everybody: How Change Happens When People Come Together
  • Book review
Show more Book review

Related Articles

Cited By...

Intended for Healthcare Professionals

BJGP Life

BJGP Open

 

Tweets by @BJGPjournal

 
 

British Journal of General Practice

NAVIGATE

  • Home
  • Current Issue
  • All Issues
  • Online First
  • Authors & reviewers

RCGP

  • BJGP for RCGP members
  • BJGP Open
  • RCGP eLearning
  • InnovAiT Journal
  • Jobs and careers

MY ACCOUNT

  • RCGP members' login
  • Subscriber login
  • Activate subscription
  • Terms and conditions

NEWS AND UPDATES

  • About BJGP
  • Alerts
  • RSS feeds
  • Facebook
  • Twitter

AUTHORS & REVIEWERS

  • Submit an article
  • Writing for BJGP: research
  • Writing for BJGP: other sections
  • BJGP editorial process & policies
  • BJGP ethical guidelines
  • Peer review for BJGP

CUSTOMER SERVICES

  • Advertising
  • Contact subscription agent
  • Copyright
  • Librarian information

CONTRIBUTE

  • BJGP Life
  • eLetters
  • Feedback

CONTACT US

BJGP Journal Office
RCGP
30 Euston Square
London NW1 2FB
Tel: +44 (0)20 3188 7400
Email: journal@rcgp.org.uk

British Journal of General Practice is an editorially-independent publication of the Royal College of General Practitioners
© 2023 British Journal of General Practice

Print ISSN: 0960-1643
Online ISSN: 1478-5242