Diagnosis and risk Management in primary care: Words That Count, Numbers That Speak

As medical students we have the privilege of observing how different doctors build up therapeutic and working relationships. The Editor’s Briefing in last September’s BJGP suggested that current medical students do not have the ‘faintest idea about how firms, departments, and hospitals work’.1 This book by Treasure addresses some of these issues and asks us to examine how the GP works.

Treasure challenges us to consider the current approach to medical training. At the end of each chapter he provides exercises for the reader to reflect on their own practice and we found these useful for our own training. The book covers many aspects of the biopsychosocial consultation, diagnosis, and the future of health services. Treasure assists us in challenging the fuzziness that he refers to in ‘the distinction between what we should be doing’ and ‘whether we are doing the right thing’. He examines how evidence, technology, and research can be synthesised to form a holistic approach in general practice and questions modern medicine’s focus on intervention.

The book is infused with Treasure’s personality and experience. The first chapter is wide-ranging and encourages the reader to consider the power of diagnostic labels and our use of language. Although he acknowledges that ethics comes into everyday cases, we feel the ethics section is too basic to be of use to most practitioners.

The book demonstrates how evidence can be used practically on a daily basis, in a way that we as medical students successfully tried out. The exercises are relevant across a variety of settings and can be performed discreetly. On testing Treasure’s consultation grid, his focus on salutogenesis (human health and wellbeing) is evident and we were able to use the model in practice. Treasure understands the value of intuition and the constraints that exist in translating the model into practice, notably of time, and economics.

The discussion of future healthcare provision in chapter two is presented as a three-way dialogue, an innovative and idiosyncratic way of enacting different viewpoints. Treasure succinctly outlines arguments about patient choice, healthcare funding, and organisation that are relevant to the modern GP. However, this style makes it relatively inaccessible for quick reference. Few diagrams are included in the book, and some of these are misleading. For example, the disease iceberg diagrams in chapter four, used to demonstrate the small real effect of certain screening programmes, are a little unclear.

What makes Treasure’s book stand out is his inclusion of the very useful and practical tool called the likelihood ratio. This tool enables us to make better-informed clinical judgments based on diagnostic test data. He provides by far the clearest explanation we have encountered of the likelihood ratio and its uses. Likelihood ratios are presented as nearest integer approximations, which are memorable and easy to apply using mental arithmetic.

In chapter six, Treasure offers a fantastic framework for developing effective communication and provides tools to ensure both doctor and patient get the most from a consultation. It is particularly comforting for the reader to hear Treasure acknowledge that, for many experienced and successful doctors, learning to communicate effectively has taken time and consideration.

As medical students we have already utilised the CAGE alcohol questionnaire likelihood ratios. Certain chapters are invaluable to those revising for the MRCGP. Chapter five, for instance, succinctly states likelihood ratios for every statement in the RCGP curriculum. Treasure advises trainers and trainees how to approach learning in a primary care environment, but fails to consider how training could be adapted for candidates from less successful demographics.

Treasure tries to explain that simple approaches and often simple diagnoses are best for both doctor and patient. Nevertheless, this is a complex book that is diverse in content and style. Does it try to cover too much? Perhaps that simply reflects the complexity of the modern GP’s role. Even so, Treasure neglects to mention some key areas of GP practice, for example, health promotion.

However, the book is still a Treasure trove. As a practical tool kit and guide, it is excellent. As a textbook and teaching aid, specific chapters are very useful for reference. We are constantly reminded to reflect on what we are observing and to maintain a critical eye. It should be more widely advertised that the book is linked to a very accessible website containing additional content and we would recommend that students and trainees read this book. It is not only useful for reflecting on how doctors can use evidence and make decisions on a daily basis, but also as a pointer on how to manage ourselves and our patients.

• © British Journal of General Practice 2013