Strategic Diagnosis and Treatment in General Medicine

Diagnosis (i.e., the act of redirecting the individual case to a “type”, among those included in a classification system) is in itself insufficient to guide the formulation of a personalized management plan and a reliable prognosis in general medicine (GM) [1]. While in many medical specialties the diagnosis brings with it a quantity of information that also points to a given etiology and/or pathogenesis, and thus significantly informs the choice of therapeutic intervention. The amount of information that the diagnosis brings with it in GM is somewhat lower [2,3]. In fact, both research evidence and clinical experience tell us that patients who share the same diagnosis often respond differently to a given treatment, while patients with different diagnoses may respond similarly to a given treatment.

At present, medicine seeks to achieve decisions based on evidence (Evidence-Based Medicine-EBM) and “precision medicine” [4]. But, on the one hand, it has become clear that identifying and synthesizing all the scientific studies that answer a question constitutes an insurmountable challenge for a clinician due to the dizzying growth in the amount of information. And besides, is it answering a question. But, since the complex patient raises many questions at the same time (What is the best treatment for a 46-year-old patient with angina, poorly controlled arterial hypertension, left ventricular hypertrophy, heart failure, diastolic disease, type 2 diabetes mellitus, diabetic nephropathy, dyslipidemia, obesity, anxiety-depressive syndrome, alcoholic liver disease, alcohol abuse, smoker, with bronchial asthma and chronic urticaria, with legal, economic, and family problems, who is religious, who is non-compliant, who is a frequent consultant, with an occasionally hostile behaviour, and who lives in a marginal area...?). The question cannot be answered by adding separate questions. It is about finding a global response. And the presence of multiple diseases increases the uncertainty about the benefits and harms of directly applying a clinical guideline, since most trials exclude patients with multiple diseases [5]. And on the other hand, in “precision medicine”, it is intended that biological markers have an important role. In GM, we do not have biomarkers ready for use in ordinary clinical practice, but we need even more, for the reasons we have just seen, an additional or global characterization of the individual case beyond diagnosis. How can we deal with this situation?: with strategic contextualization.

In the time of the pharaohs, there was an important temple in Egypt located behind the Nubian Falls, in what is now the desert of northern Sudan. Three rivers join in that region to form the Nile, achieving the annual miracle of its flooding that allows farmers to grow grain in the extremely dry climate. Every spring, the high priest of the temple would go to the bridge over the Nile to observe the colour of the water. If it was clear, it was the White Nile, flowing from Lake Victoria through the swamps of the Sudan that would dominate the channel. The flood would be light and late; farmers would produce a minimal grain crop. If the river appeared dark, the strong currents of the Blue Nile, which joined the White Nile at Khartoum, would prevail. The flood would be enough to saturate the fields and provide a good harvest. Finally, if the river waters were predominantly greenish brown, they came from the Atbara, flowing rapidly from the Ethiopian highlands, and then there would be very rapid and catastrophically intense flooding would be drowned; The Pharaoh should keep wheat in reserve. Every year the priest sent messengers to Pharaoh to inform him of the colour of the waters. Thus, he knew how prosperous the peasants of his kingdom would be, and how much he could raise taxes, so that he would know if he could afford to start the conquest of other territories.

The process of making diagnoses and treatments in GM begins in the same way as the priest did, looking at the main forces or actors, for what are the key forces and actors relationships that influence the outcomes of events. These key elements (with energy) determine the argument and result of the patient’s health/disease history. It’s like the motive in a detective story. In fact, the task of the general practitioner (GP) is like that of the detective, searching for the hidden forces that clarify the inexplicable murder. Without key forces, diagnosis and treatment cannot be thought of. Finding these key elements early is critical to decision making, and we can leave other lesser forces out of our focus. The GP has to have a plan. It is not about waiting for an inspiration; it is about finding the significant event that never ceases to occur. The question is to detect it and take advantage of it.

The key forces of a patient’s health/disease scenario may be obvious to one person and hidden from another, so it is better to build diagnoses and treatments as a team (after doing the investigative work individually): doctor, patient, family, other actors, nurse, social worker, specialists, pharmacist, healer… The aviation industry has developed, but only after many small forces converged-engine research, air traffic control development, government support for airports, etc. Cars cannot truly function without paved roads, gas stations, tires, rubber industries, car design, assembly lines, and the vast network of highways and streets. If someone wants to make major changes to automobiles (like design electric cars, or cars that run on rails), they can’t just design a machine. You have to think about changing the network of systems that support the car. Similarly, to plan the intervention on a patient, the context (family, group, community systems) that surrounds him must be included.

Strategic diagnosis and treatment is directed towards the context. The environment constitutes the criteria for making decisions; seeks competitive advantage, diversifications, opportunities, advantages and threats. When a strategy is built, it is not intended to make decisions about the future at the moment, but to make decisions taking the future into account. Strategy is not an end in itself, but only a means. It must be constantly reassessed and readjusted based on changes [6].

The GP today needs a systematic guide, which current diagnostic systems and related tools do not provide or do not provide satisfactorily, thus contributing to a therapeutic practice that, guided only by diagnostic labels, is often over-simplified and stereotyped [6].

The strategic contextual analysis allows seeing beyond the knot of the complex question. It is aimed at knowing resources and potential for the achievement of goals. It can make it possible to overcome resistance to change and create favourable conditions for medical intervention. Strategic questions when planning the intervention include the following: who will be affected by the physician’s intervention, who could stop the medical action, who could facilitate implementation, what are the strengths and weaknesses of the patient and his family? What are the interests of the patient? Have the objectives of the medical intervention been agreed upon with the main actors? The final stretch of a race is the outcome of a drama outlined long before. Finding the element defines the system. “Know your enemy and know yourself and in 100 battles you will never be defeated”.

1. Turabian JL, Perez Franco B (2010) The concept of treatment in family medicine: A contextualised and contextual map of a city hardly seen. Atent Primaria 42(5): 253-254.
2. Maj M (2018) Why the clinical utility of diagnostic categories in psychiatry is intrinsically limited and how we can use new approaches to complement them. World Psychiatry 17(2): 121-122.
3. Turabian JL (2017) Fables of family medicine. A collection of fables that teach the principles of family medicine. Editorial Académica Española, Saarbrücken, Germany.
4. National Research Council of the National Academies (2011) Toward precision medicine. Building a knowledge network for biomedical research and a new taxonomy of disease. National Academies Press, Washington, USA.
5. Turabian JL, Perez Franco B (2014) Album of models for qualitative tools in the Family Medicine decision making. Other maps to describe a country. Semergen, Madrid, Spain 40(8): 415-424.
6. Mcneilly M (2011) Sun Tzu and the art of business. Six strategic principles for managers. Revised Edition. Oxford University Press.