medical problem-solving: a five stage approach in primary medical care

Medical problem-solving: a ®ve stage approach in primary

medical care

R J E Erasmus,1 P W W Coetzer2 & I T Hay3

1Department of Family Medicine, University of Pretoria, Pretoria;2Department of Community Health, Medunsa and3Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa

SUMMARY

A methodology for a ®ve stage or pentagonal problem-

based approach to solve individual or family health-

related problems is described. The model can be ap-

plied in health worker learning, student teaching or

problem solving in the real world of the patient and his/

her family within the context of community health. The

model stresses interdisciplinary co-operation, the con-

sideration of ethical factors in each case, and a logical

transition from individual patient care to community

diagnosis and intervention. The model is applicable to

any disease process, all levels of care, all levels of in-

tervention and all clinical disciplines.

Keywords

*Decision support techniques; *primary health care;

*problem solving

INTRODUCTION

The task of the health care professional is twofold: to

understand the patient and to understand the disease

(Levenstein et al. 1986). The process of dealing with a

patient's presenting problem or main complaint by

setting a differential diagnosis and reaching the appro-

priate diagnosis by eliminating possibilities is the well-

tried clinical method through which diseases are

understood, but unfortunately an equivalent method

for understanding patients as people is not generally

taught or utilized in modern health care practice.

McWhinney (1989) describes the biomedical model

as the `traditional clinical method', which is strictly ob-

jective, with the sole purpose of diagnosing the disease

instead of attempting to understand the patient who

presents with a health-related problem. The biomedical

approach also fails to recognize what the problem or

symptom means to the patient, as well as the context in

which the patient ®nds him or herself. In the traditional

clinical method a history of the presenting complaint,

symptom or problem, past medical and family history is

usually taken by interviewing the patient through closed

questions. Most health care professionals assume that

the meeting with the patient will be conducted accord-

ing to the agenda of the former and the patient is seldom

allowed to add to, or modify, the agenda. The history is

then followed by a systematic clinical examination which

tends to produce information or evidence with very low

sensitivity and speci®city on which a differential diag-

nosis is formulated. In order to reach a diagnosis, a

number of investigations are performed to cover all or

most possibilities, either by exclusion or con®rmation of

the diagnosis. Unfortunately, a large proportion of pa-

tients who present with health-related problems to

family doctors remain without a speci®c diagnosis and

therefore the doctor must have some other way of

reaching an understanding of the illness.

The pentagonal approach to problem-solving as an

andragogic model was developed by the authors from the

biopsychosocial model (Engel 1977) to enable health

care professionals to manage the problems with which

patients present, especially those where a clear biomed-

ical assessment or diagnosis and management is not

possible. This ®ve stage approach consists of individual,

clinical, microcontextual (family and immediate sur-

roundings), macrocontextual (community health) and

ethical components on which an assessment and man-

agement plan for the problem can be based. The term

`pentagonal' was elected to stress the equal importance of

each of the ®ve components of the assessment. Each of

the components can be regarded as a system in terms of

classical systems theory because each component de-

pends on the other and any change that occurs in one

system may affect any of the other systems. The personal

or individual characteristics of the patient will have an

effect on how a speci®c clinical problem or diagnosis is

experienced by the patient, which will in¯uence or be

in¯uenced by the microcontext (family and immediate

surroundings) in which the patient exists, and this will

Correspondence: Professor I T Hay, Department of Paediatrics, Faculty of Medicine, Kalafong Hospital, Klinikala Building, Private Bag X396,

Pretoria 0001, South Africa

435 MEDICAL EDUCATION 1997, 31, 435±439 Ó 1997 Blackwell Science Ltd

in¯uence or be in¯uenced by the macrocontextual

(community health) aspects related to the patient or the

illness (diagnosis or health related problem). Each one

of these components can also be regarded as a system

in terms of systems theory which seeks to address

problems by including all the signi®cant relationships.

Some of the components are subsystems of other

components, but the ethical component traverses all

other components. The systems re¯ected in Fig. 1 are

therefore represented as typical hierarchical systems.

In the systematic discussion below, however, the

systems are not treated in order of magnitude or com-

plexity, but in order of the natural (temporal) sequence

adopted by the clinician in the problem solving process.

Under certain circumstances it may be necessary to

alter the usual temporal sequence of the assessment. In

whatever sequential order the systems are processed the

approach should be holistic with appropriate attention

to inputs and outputs, the relationships of the subsys-

tems to each other and feedback loops.

INDIVIDUAL COMPONENT

A consultation is conceived when an individual

becomes a patient, a transformation process that is ill-

understood, even in modern day medicine. The clini-

cian±patient relationship, which forms the foundation

of any therapeutic intervention, may start long before

the actual meeting takes place, because the person who

has decided to become a patient usually has a precon-

ceived opinion of the health service provider, based on

previous experience or knowledge (Capra 1982). The

patient should therefore be considered by the doctor as

a person, with special attention to personality traits,

emotions, fears, expectations and speci®c help-seeking

behaviour. Attention should also be given to the pa-

tient's experience with the health service in dealing with

previous or current problems because the subjectivity of

the problem might determine to a greater or lesser ex-

tent what the patient expects from the health care

worker and health care system.

The individual component of the pentagonal ap-

proach thus means that the primary health care provider

is obliged to accept and approach every patient as an

individual with fears, expectations, beliefs and, above all,

self-knowledge and insight. This is because the foun-

dation of health care lies in the patient±health worker

relationship and the quality of the latter depends to a

large extent on the subjective aspects of both the patient

and the health worker. The patient±health worker rela-

tionship has intrinsic therapeutic value with speci®c in-

dications, contra-indications, side effects and dosage. In

the non-emergency situation the doctor would normally

assess the patient as an individual or (whole) person ®rst

before progressing to the clinical component. The

question of full or part payment for services by the pa-

tient must also be addressed here (if applicable) as part

of the ethical assessment of problem-solving.

CLINICAL COMPONENT

The patient's problem should be assessed clinically by

application of the biomedical clinical method which

includes the process of differential diagnoses and

special investigations, but both must be based on

probabilities rather than possibilities. According to

Fehrsen & Henbest (1993) the family doctor (and

other primary health care providers) works within a

very complex web of systems when dealing with pa-

tients as people and the clinical component represents

all levels below the person, namely the atom, mole-

cule, cell, organ and organ systems. When clinicians

work in the biomedical (or reductionistic) mode, they

typically delve deeper and deeper into the clinical area,

with more and more sophisticated and costly investi-

gations, often precipitating new iatrogenic problems.

In the systems approach, they can penetrate deeper

inside and/or search outside in ever widening circles

for a `best-®t' understanding of the problem. In certain

emergencies, e.g. a stabbed heart or asphyxiation, the

clinical diagnosis would precede the individual as-

sessment, which will be deferred until after resuscita-

tion or emergency intervention.

Figure 1 The ®ve components of the pentagonal approach ac-

cording to classical systems theory.


Problem-solving in primary medical care R J E Erasmus et al.

MICROCONTEXTUAL COMPONENT

The patient's microcontext consists predominantly of

his/her occupation and family, or those people with

whom a household is shared. Caring for the patient in

the family and family as patient is central to the phi-

losophy of modern family medicine. The in¯uence a

health-related problem has on the family, as well as the

in¯uence of the family on the health-related problem, is

of cardinal importance to the primary care or family

doctor. The family should always be utilized as a re-

source of information and support. The family doctor's

understanding of a family's relationships, his or her

power to predict problems, and his or her capacity to

help are greatly enhanced by caring for the whole family

unit (McWhinney 1989). The microcontextual com-

ponent also includes the work, leisure and in transit

(travel) environments, and their physico-chemical, bi-

ological and social elements.

MACROCONTEXTUAL (COMMUNITY

HEALTH) COMPONENT

The patient and family live in a community which in-

¯uences the individual and family to a greater or lesser

degree. The health-related problems of the individual

patient are often related to environmental factors,

especially regarding infectious diseases, but also to

psychosocial problems such as stress, depression and

violence. The community consists not only of the

suburb or township, but also of larger environment

ranging from the district, province, country, continent

and ultimately the universe.

The macrocontextual or community health compo-

nent is of vital importance as part of measuring or as-

sessing the health care system rather than the patient

and his/her family. The macrocontext in¯uences the

whole community (not only the patient) and the indi-

vidual health care worker can do little to improve

matters in this regard. It is therefore of vital importance

that the information regarding the circumstances of the

individual patients should be transferred to the com-

munity doctor who must manipulate the larger systems

of community health which consists of health care

management components, environmental health com-

ponents and epidemiologic surveillance systems. In all

these systems the patient is no longer regarded as an

individual with a name, fears, expectations and beliefs.

He or she becomes a number, element or index case in

a larger picture and is now divided into gender, age,

occupation, risk factors, spatial co-ordinates and time

frames. All this information is necessary to improve the

health care system in order to reduce mortality and

morbidity in groups, rather than in individuals. These

actions are undertaken by superintendents, medical

of®cers of health, district health of®cers and director-

ates (mangers) of provincial and central health services.

As a handy checklist the macrocontextual or commu-

nity assessment can be considered under the following

three headings:

1. The administrative health care component.

This includes legal aspects such as noti®ability; legal

obligations of doctors; exclusion from schools; con-

tractual liability and professional responsibility; prob-

lems with medical records; referrals to secondary and

tertiary institutions; patient transport; waiting times;

and the availability and acceptability of services.

2. Epidemiological component. The patient be-

comes an element or index case in the outbreak, epi-

demic or endemic disease pattern of the health-related

condition from which he/she suffers. Without adequate

epidemiological data meaningful intervention at the

community level is not possible.

3. Environmental health component. This does

not consider the physical environment of the patient as

an individual but that of the community (or part

thereof) as a whole. It addresses, amongst others, issues

such as water, sanitation, housing, refuse removal, oc-

cupational hygiene, nutrition and protection from vio-

lence and accidents.

Figure 2 The pentagonal approach: the patient and his/her en-

vironment.



Table 1 The application of the pentagonal approach to a particular case study

Mode of assessment Salient features Ethical assessment

Individual assessment · The grandmother is the surrogate mother · Was it wrong for the grandmother to take the child to a

traditional healer ®rst?

· The child is under severe emotional and

physical stress

· Will the child be optimally cared for by addressing the

grandmother's (animistic) spiritual

· The grandmother believes that the child

has been bewitched and that

beliefs?

health care professionals will be unable to

break the spell

· How much autonomy does the child and her grand-

mother have?

· The grandmother is starting to be

ambivalent towards her granddaughter:

· Can the grandmother give consent for the operation?

± she loves her but wishes her daughter to

return and carry out her

· Should the grandmother be counselled that the child

has AIDS and that her prognosis is hopeless?

maternal obligations · Who is ethically responsible or nurturing this child now

and when can the child be removed to a hospital or

hospice against the grandmother's will?

· Is the professional caretaker practising bene®cence

when he or she extracts the last second of life from a

dying patient? Is it sometimes ethical to kill? If so,

when?

Clinical assessment · Long-standing ``failure to thrive''

· Gastro-enteritis

· What potentially painful and expensive diagnostic tests

should be performed on this child, whose social and

· Oral thrush clinical prognosis is pretty dismal?

· Broncho-pneumonia

· Fluctuating abscess of thigh

· Under what circumstances may the clinician withhold

the diagnosis from the grandmother?

· Clinical AIDS · When, if ever, will it be ethical to exchange vigorous,

de®nitive treatment for palliation only?

Microcontextual

assessment

· The nuclear family is (permanently)

disrupted

· Should any effort be made to trace the mother and

father?

· There is abject poverty, with little hope

of relief

· How much State resources should be spent on trying to

mend this disintegrated family?

· The staple of maize meal cannot supply

the daily required nutrients

· Who is responsible to provide safe water for this family

only?

· The family water supply is almost

certainly contaminated

· Should the local Sangoma be allowed to ``diagnose and

treat'' AIDS?

· The local Sangoma claims that she can

diagnose and treat AIDS

Macrocontextual

assessment

· HIV infection is not legally noti®able in

South Africa

· Which proportion of the health budget should be spent

on HIV infection and AIDS?

· The National HIV and AIDS epidemic is

out of control

· Should the emphasis be on prevention, vigorous treat-

ment or palliative care in hospices?

· No housing, refuse removal, clean water

provision, or electricity are

· Will the ethical rules change when the prevalence of

HIV infection in the total population reaches 35%

available for the total local population (or even 50%)? If so, how?

· Primary health care services are available

only on Mondays through a

· Is abortion ethical after 14 weeks duration of pregnancy

in patients who are HIV positive?

mobile clinic. The nearest ®xed clinic is

25 km distant

· Will money spent on agriculture, education, housing,

sanitation and safe water buy more health than the

· There are no community support

services to which the family can turn for

supply of health services?

help · Should a populist democratic process take these deci-

sions, even if it discriminates against patients who

are HIV positive?



Conversely, the macrocontextual environment can-

not be ignored by the family doctor when assessing the

patient and the family.

ETHICAL COMPONENT

Every patient contact has ethical implications which

should be assessed and brought into consideration by

the health care professional. Examples of common

ethical dilemmas confronting the family doctor and

other primary health care professionals are: the control

of information; the patient±doctor relationship; bene-

®cence; patient autonomy; paternalism; con¯ict of

moral values; hateful patients; referrals; advocacy and

distributive justice (Christie & Hoffmaster 1986).

During every consultation the cost-effectiveness of

special investigations and treatment should be ad-

dressed by asking: ``How much quality health-care is

acquired with the money spent and will it in¯uence my

management and the progress of the problem?'' Wast-

ing a patient's (or the taxpayer's) health care money

could be considered unethical behaviour. All levels of

assessment contain one or more actual or potential

ethical problems (Fig. 1). Another conceptual model of

the pentagonal approach is presented in Fig. 2.

HOW CAN THE PENTAGONAL

APPROACH BE APPLIED

IN PRACTICE?

The following case study serves to illustrate the appli-

cation of the pentagonal approach in problem-solving

in primary care.

A 2-year-old child, living in a rural area, is taken to a

mobile clinic by her grandmother. The child has been

failing to thrive and has had a chronic cough and per-

sistent diarrhoea. On enquiry her grandmother provides

the history that a traditional healer (sangoma) has been

consulted. She believes that the child is bewitched and

has given her traditional medicines. On examination

the child is marasmic, has generalized lymphadenopa-

thy, severe oral candidiasis, bronchopneumonia and a

¯uctuant abscess on her thigh. HIV/AIDS is the prob-

able diagnosis. The application of the pentagonal ap-

proach to this case study appears in Table 1.

The authors have utilized this model for the past 5

years at a large regional hospital teaching both under-

graduate and postgraduate medical students in small

groups. Each student prepared a pentagonal assessment

for one of his/her patients, which included a home visit.

At the bedside the nurse, social worker (when avail-

able), family doctor, paediatrician and community

health specialist were present. The student then sys-

tematically presented the case and the clinical diagnosis

was discussed by the paediatrician, the individual and

microcontextual assessment by the family doctor, the

macrocontextual assessment by the community health

specialist, and the ethical assessment by all concerned,

including the nurse and social worker. In practice the

authors found that the students had no problems in

grasping or utilizing the pentagonal approach but that

new specialist consultants were hesitant (and perhaps

vulnerable) in utilizing this approach in the presence of

very critical and alert students. Once mutual trust was

established, however, very few problems were encoun-

tered. For the past 3 years the model has also been

employed with success at another medical school, the

corporate culture of which is markedly different from

that of the ®rst.

It is readily appreciated that effective use of the pen-

tagonal approach requires a change in the way the clin-

ical practitioner conceives his/her clinical practice role.

CONCLUSION

The primary health care provider is often confronted

with patients in whom a clear clinical diagnosis is not

possible. The pentagonal approach provides a frame-

work which should be utilized in every primary care

consultation in order to improve the quality of care for

the patient, work satisfaction of the health care provider

and the patient±doctor relationship. A more formal and

rigorous evaluation of the model by clinical teachers not

involved in its initial conception is invited.

REFERENCES

Capra F (1982) The Turning Point. Bantam Books, New York.

Christie R J & Hoffmaster C B (1986) Ethical Issues in Family

Medicine. Oxford University Press, New York.

Engel G L (1977) The need for a new medical model: a challenge

for biomedicine. Science 196, 129±36.

Fehrsen G S & Henbest R J (1993) In search of excellence. Ex-

panding the patient centered clinical method: a three stage

assessment. Family Practice 10, 49±54.

Levenstein J H, McCracken E C, McWhinney I R, Stewart M A &

Brown J B (1986) The patient-centred clinical method. 1. A

model for the doctor-patient interaction in family medicine.

Family Practice 3, 24±30.

McWhinney I R (1989) A Textbook of Family Medicine. Oxford

University Press, New York.

Received 8 July 1996; editorial comments to authors 15 August 1996;

accepted for publication 21 November 1996



medical problem-solving: a five stage approach in primary medical care

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