Importance of symptoms in family medicine

When I left the hospital I knew an awful lot. The problem was that the patients didn’t have anything I knew about.

                                                                                                     Dr Martin Bass*

One of the most interesting and challenging parts of family medicine is the management of patients’ symptoms.

Kathryn Montgomery, in her remarkable book How Doctors Think, has described the practice of medicine as neither science nor art but as what Aristotle called phronesis—a “practical craft” informed by science and research.¹ If that is so, what are the key elements of the practical craft of the skilled family physician? Dr Iona Heath has written that the unique skill of the general practitioner is to patrol the boundaries between symptoms and the diseases that we can diagnose and treat, and between the diseases that we can diagnose and treat and those that require specialist or hospital care.²

Generalist family physicians see and manage symptoms as much as they see and manage diseases; this is likely to become more challenging as the population continues to age and people live with several chronic diseases or conditions. Yet both undergraduate and postgraduate medical education for family physicians are predominantly focused on diseases, not symptoms, thereby limiting the development of our practical generalist craft. Understanding diseases and their typical presentations is important, but for family physicians, understanding symptoms and their natural history is also essential. Why is this the case? How can we strengthen this part of our training and practice?

In a previous commentary in Canadian Family Physician,³ Drs Thomas R. Freeman and Moira Stewart* described that the evaluation and, where possible, alleviation of symptoms are substantial portions of the work family physicians do, but until recently there has been relatively little research on symptoms. Happily, that is changing owing to 2 main factors: large databases derived from anonymized, aggregated data from electronic medical records; and a coding system that allows for recording the reason for encounters, including symptoms (International Classification of Primary Care⁴).

This month’s Canadian Family Physician features an important research study from Drs Freeman and Stewart and their colleagues at Western University in London, Ont, describing the natural history of abdominal pain, one of the most common symptoms family physicians see (page 341).⁵ This retrospective cohort study, conducted over 4 years, involved patients presenting with abdominal pain to 18 family physicians in 8 group practices in southwestern Ontario. The authors identified and studied 3 subtypes and “pathways” of abdominal pain that differed in clinically important ways. Perhaps this was the most surprising and important finding:

The most frequent pathway was that the symptom remained with no diagnosis, suggesting a need for clinical approaches and education programs for care of symptoms themselves, not merely in the service of coming to a diagnosis.⁵

Although the study has several limitations, including that it was small and from a particular geographic setting, the prospect of there being larger future studies of abdominal pain and other common symptoms presenting in family medicine bodes well for deepening our understanding of this, until now, poorly understood aspect of our practical craft.

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