General Practice 2 Malta Handbook 2021/22
Site: | QMplus - The Online Learning Environment of Queen Mary University of London |
Module: | GP Tutor Site |
Book: | General Practice 2 Malta Handbook 2021/22 |
Printed by: | Guest user |
Date: | Thursday, 5 December 2024, 9:32 AM |
Description
General Practice 2 Handbook
1. Course Administration and Clinical Leads
Contact details for Unit Convenors
Maria
Hayfron-Benjamin
m.j.hayfron-benjamin@qmul.ac.uk
Dr Lucy Langford
Contact details for Unit Administrators
Unit Administrator
Rachel Portelli
2. Introduction
This is a community based placement for all Year 2 students at Barts Malta. Students need to continue to meet patients, building on their experiences in Medicine in Society in Year 1 and continue their professional development with the benefit of authentic clinical experiences.
General practice will work as a setting which will bring to life the PBL scenarios, contextualising and broadening your learning and encouraging you to think about the wider, more varied, range of disease presentation. The opportunity to actively engage with patients in a safe, yet authentic, clinical environment will allow you to reflect on your communication skills and your attitudes to patients and illness, forming an important aspect of their professional development.
MODULE AIMS:
To build on the general practice experience and patient contact in Medicine in Society in Year 1, bring to life the ‘core’ conditions covered in the PBL sessions with clinical experience.
LEARNING OUTCOMES:
By the end of this unit, students should be able to:
- Apply their theoretical knowledge to clinical situations,
- Communicate appropriately with patients,
- Identify the variety of patients’ concerns about their health
- Describe the patients perspective of illness, it's treatment and the impact on them and their families
- Perform appropriate clinical examinations such as blood pressure and other basic examinations under adequate supervision (practice of these skills will happen in MedSoc 2 and in clinical skills)
- Use their observation of senior colleagues in clinical practice to reflect on the attributes required of them as professionals
3. Course Description
You will be with a GP tutor for a day of teaching on 6 occasion through the year. For this academic year your General Practice 2 teaching will be online and will be delivered via Microsoft Teams.
It is expected that each day will begin with a preparatory tutorial, where you will have an opportunity to discuss your learning needs. This will be followed by some group activity e.g. preparing a short presentation on the conditions that the patients you will meet may have. You will also do some work to prepare to meet a patient. You will also have opportunities to practise communication skills. It is likely that most if not all of your encounters will be conducted online or via telephone.
You will work in small groups for these activities and will be expected to give feedback to your colleagues; you will also receive feedback from your tutor.
4. Timetable
Week | Group AB (A) | Group CD (B) | System |
1 | 26/10/21 | 19/10/21 | Chronic disease |
2 | 23/11/21 | 16/11/21 | Food and Health |
3 | 18/01/22 | 11/1/22 | Mental health and physical health |
4 | 8/2/22 | 1/2/22 | The life of a child |
5 | 8/3/22 | 1/3/22 | Getting older |
6 | 26/4/22 | 5/4/22 | Limited mobility |
4.1. Clinical conditions to be covered
SUGGESTED TOPICS TO BE COVERED IN GP2 SESSION
Day |
Theme |
Suggested topics
|
1 |
Chronic health problems |
asthma, diabetes, CHD, stroke |
2 |
Food and health |
nutrition and health, obesity, inflammatory and irritable bowel diseases |
3 |
Mental and physical health |
reduced life expectancy, smoking, physical activity |
4 |
The life of a child |
development, neurodiversity, chronic ill health and the impact on the family |
5 |
Getting older |
normal ageing, frailty, dementia, |
6 |
Limited mobility |
arthritis, stroke, MS, obesity, pain |
|
4.2. Sample lesson plan for GP 2
GENERIC STRUCTURE: THIS IS ONLY MEANT AS A SUGGESTED TEMPLATE FOR A DAY AND TUTORS ARE OF COURSE FREE TO DESIGN AND RUN THEIR TEACHING SESSIONS HOWEVER THEY WISH TO.
9.30 – 10.15 | Intro - Outline topic/s and plan for the day. Activity 1 – e.g. tutorial, which could include students presenting “homework” set at previous session. On day 1 this time should be spent getting to know each other with some icebreaker activities - you might like the students to tell you one memorable thing about themselves - you might start by telling them that you grow roses, are scared of spiders, play guitar with a band, have a dog called Snoopy... You might also like to explore whether they know each other - they may not have met in person. Discuss your plan for the day |
10.15 – 11.15 | Activity 2 - e.g. students complete tasks in breakout groups; students in groups of 2 or 3 to prepare short presentations of conditions related to the theme for the day or related to a patient they are going to meet later. They might read a paper, look at guidelines, look up some relevant drug. Brief presentation and discussion |
11.15 – 11.30 | Break |
11.30 – 13.00 | Activity 3 - e.g. patient encounters – virtual or face-to-face; prepare questions and/or observations. Students present patients, with a focus on different aspect of history taking, e.g. you might focus on Presenting complaint and PMHx , one week, social history another week, drug history and allergies another week so they have a clearer picture of the value of each element of the history Debrief and close |
In Malta the expectation in that there will be about 3.5 hours of interaction with a GP tutor over the course of the day, the timing may need to be negotiated if the tutor is working clinically on that day. The tutor might ask students to do some preparatory work in the morning and then spend the afternoon together, or you might spend two hours together in the morning then a gap for student group work then an hour or two together later in the day.
The structure of each day should be communicated to students in advance if possible using the Team as a means of communication.
Examples of activities that could be delivered virtually or face-to-face:
Tutorials
Student presentations
Online research
Debates
Group discussions
Quizzes/Polls
Role-plays – either in small groups or as whole group with fish bowel set-up (consider specific observation tasks for feedback and discussion)
Case-based discussions
Patient encounters –expert patients with group/small groups, students interview patients in pairs/small groups, home visits
Observing GPs and other healthcare professionals
Interviewing members of primary care team
Joining practice team, or wider MDT, meetings
Reviewing recent journal articles and media publications, especially to discuss current 'hot topics'
Please note this list is not exhaustive. Ideally each day would include mix of activities, prioritising any patient encounters. There may be times when the not all students from the group are completing the same activity, for example if 4 students are able to attend the practice in person they might go on home visits whilst the online group meet an expert patient and afterwards the whole group reconvenes to discuss their experiences and learning.
5. Student Assessment
ATTENDANCE
Tutors are required to complete a placement attendance register, this must be returned with the grade sheets and Professionalism Assessment forms at the end of the unit.
Student attendance should be recorded on each placement day. Tutors should inform the medical school of any unexplained non-attendance at online or practice based teaching so we can check on the welfare of the student.
Any student unable to attend must submit a self certificate form the University.
ASSESSMENT
During the year students will complete a creative/reflective case study which will be submitted for assessment.
Students will also be assessed on their professionalism.
5.1. Reflective/creative case study
Students must write a 500 - 1000 word reflective essay about a patient that has had an impact on them. This should ideally be someone they met through the GP 2 placement but might be someone they met elsewhere.
The focus of the work should be on why this patient had a resonance for them and how that might affect their interaction with patients in the future. For example you might describe a patient with schizophrenia who is of a similar age to you but is on a different life course, an elderly patient with dementia may have a particular resonance if you have a grandparent with dementia, you may have a family member with cancer, or you may have experience of ill-health yourself and that may affect how you relate to patients.
You should support your writing with a creative piece for example a photograph, a drawing, a poem that helps to tell the story you want to tell.
The piece of work must be submitted to your tutor and to QM+ by Day 5 of your placement i.e. 1/3/22 (CD) or 8/3/22 (AB)
Guidance for grading the reflective piece
| Merit | Pass | Referred |
Impact | The work moves/engages you. It stays with you/ opens new doors & new perspectives
| There were some interesting insights and perspectives that made you think but could have been explored further. | Themes/ideas addressed superficially. |
Reflection
| Insightful reflection - focused on ‘key issues/ideas,’ explored from different perspectives, context and emotions are considered.
| Mix of descriptive account with some reflection e.g., the student considers their emotions, looks at the perspective of others, or identifies ‘key issues/ideas,’ but this could be expanded.
| Descriptive account – narrative account of what happened, with little or no reflection.
|
Aesthetics (If creative enquiry piece included) | Excellent use of chosen medium powerfully conveying the content, assisting the audience in engaging with the message. | Some originality. Reasonable effort and use of chosen medium. | Little original thought, little effort, not effective use of medium chosen, not conveying the content well. |
Feedback to students could include:
Points of excellence
Points for improvement - could include questions/prompts to encourage continued reflection
General comments
5.2. Professionalism assessment
As part of the final assessment tutors must complete a Professionalism Assessment on each student. Tutors are asked to give students formative feedback on their professionalism when they review progress during the year so students have opportunities to modify their behaviour before they are formally assessed at the end of the year.
6. Ethics and Confidentiality
ONLINE SAFETY
Please refer to the CBME virtual teaching website, which includes information about confidentiality and consent relating to virtual teaching involving patients; there are links to both GMC and BMA (British Medical Association) guidance as well.
Please remind all students of the importance of patient confidentiality when they begin their placement with you, this should include outlining your practice procedures to maintain confidentiality and examples of how they might inadvertently breach confidentiality e.g. discussing a patient in a public area within or outside the practice; discussing one patient with another; or including patient identifiable data on notes they have made as a resource for their own learning.
- For further information please see – GMC guidance - Medical Students: Professional values and fitness to practise: http://www.gmc-uk.org/education/undergraduate/professional_behaviour.asp
- Or the GMC guide to Confidentiality which includes some case studies and learning resources: http://www.gmc-uk.org/guidance/ethical_guidance/confidentiality.asp
- and includes information specifically related to sharing information with medical students: http://www.gmc- uk.org/Confidentiality_disclosing_info_education_2009.pdf_27493403.pdf
Students will be seeing patients either in the GP surgery or visiting them in their own home. They have been asked to bear in mind the following:
- Patients have a right to confidentiality; therefore please ensure you do not discuss any personal patient information outside of the practice.
- Although patients should have been informed prior to the session that medical students will be present, you must respect their wishes if they decline to be interviewed or examined by any student.
- Treat all patients and staff with courtesy and respect, they are generally going out of their way to provide a valuable learning experience for you.
- Please ensure that you are neatly attired.
- Please remember that, even though the tutor may have gained consent from the
- patient, it is important that you reaffirm that consent personally.
7. Appendices
Further information can be found in the appendices
7.1. LEARNING THROUGH REFLECTION & CREATIVE ENQUIRY
Reflection is a key skill for all healthcare professionals and learning how to develop reflective practice is an essential part of medical education. The GMC (General Medical Council), in collaboration with the Academy of Medical Royal Colleges, the UK Conference of Postgraduate Medical Deans (COPMeD), and the Medical Schools Council (MSC), recently published a guide for medical students on how to reflect as part of their practice.
The key idea of reflective work is to promote self-awareness. It enables students to explore their understanding of themselves as medical professionals and how they relate to patients. It also provides a space where students can consider and challenge their own attitudes and perceptions, including highlighting learning points for themselves and others.
There are many formats that can be used for reflection, including verbal, written and art. Creative enquiry is an educational approach that invites learners to engage with their lived experience through the arts. Using multiple languages of expression, arts-based and prose reflective writing, has been found to extend reflection and understanding and engage the student voice and perspective. The websites, Human Flourishing and Out of Our Heads, have more information about creative enquiry and lots of examples.
7.2. TUTOR CHECKLIST
Action | Tick when completed |
Before placement starts |
|
Find the GP2 2021-22 course guide on the CBME tutor website - please ensure you are using this year’s guide
| |
Send welcome introductory email to your students to advise them of arrangements for day 1
|
|
Access to Virtual Primary Care (VPC) - you will be sent an email inviting you to register for a VPC account; log in prior to the placement starting and check you can see the GP2 playlists
|
|
Attend GP2 induction training (online) Tuesday 12th October 2-4pm If you cannot attend, please review training slides
|
|
Complete e-Learning for Healthcare – Freedom to Speak Up (You will need to set up an account) - Malta tutors should be able to access this resource using your QMUL address that you use to access Virtual Primary Care. We all find it difficult to speak up when we experience something that concerns us. This is especially true for learners. To create safe ‘SPEAKING UP’ culture and help students develop valuable skills the medical school would like all clinical supervisors to complete the short ‘LISTEN UP’ online module
|
|
On Day 1 |
|
Share student learning agreement with students. Collect signed student learning agreement (SLA) from students, countersign and return copies to students
| |
Agree group ground rules, routes for contact (Teams, email, WhatsApp etc) and reporting absences.
|
|
7.3. STUDENT CHECKLIST
Action | Tick when completed |
Before placement starts |
|
Ensure you know which group you are in and check that you can access your Team
| |
Complete the Complete the Preparation for Placements online learning module
|
|
Join a medical defence union e.g., MPS or MDU Student membership is free - Malta students please follow local guidance
|
|
Access to Virtual Primary Care (VPC) - you will be sent an email inviting you to register for a VPC account; registrar and log in prior to the placement starting
|
|
Find the GP2 2021-22 course guide on QMplus – log into QM+ and locate the GP2 course guide (under the clinical placements tab)
|
|
On Day 1 |
|
Read and sign the student learning agreement (SLA)
| |
Agree group ground rules, routes for contact (Teams, email, WhatsApp etc) and reporting absences (any absences must be reported to your GP tutor and to QMUL via form on QMplus)
|
|
If you have any queries, or difficulty in accessing any specific resources, please ask your peers, GP tutor or module administrator/convenors as appropriate.
7.4. STUDENT LEARNING AGREEMENT
To be signed by each student and emailed to their GP tutor
Purpose:
The Learning Agreement lays out the responsibilities that students, their supervisors, host GP practices and the medical school have to each other. It emphasises the mutual roles of learners and teachers for a successful clinical placement; that maintains safety for all.
The Supervising GP Tutor will have overall responsibility for the quality and organisation of the placement ensuring the student (s), have:
An induction
A named supervising GP Tutor for each day
A way to contact the practice in case of problems
An initial learning needs assessment and a final meeting where we will discuss performance and feedback from others and plan for further development
A safe, active, open leaning environment with opportunity to discuss any problems
In addition, where students can physically attend placement
PPE for all F2F patient encounters
Implemented current guidance for COVID-19 Risk Reduction (see attached checklist) including protecting shielding colleagues
Appropriate access to patient records and access to the internet
As a Medical Student my responsibilities are to:
Complete any assessments and upload them in good time
Adhere to all student professionalism guidance, codes of conduct & Good Medical Practice
Prioritise patient safety by assessing and minimising any risk to patients and staff
Strictly follow national guidance on PPE, face coverings, and all COVID-19 risk mitigations at all times (both on placement and in my private time)
Follow local COVID-19 advice and Test, Track and Trace requirements
Be honest and open with my supervisors about my prior performance, strengths, and areas to improve and any special requirements
Seek and respond to my feedback to hone capabilities in clinical supervision
Cease clinical work if I find myself in a situation where I do not have a qualified healthcare professional to supervise me until the situation is remedied
Always identify myself to patients, relatives and staff and in medical records as a Medical Student
Advise my GP Tutor of any absences as soon as possible and agree how my duties will be carried out in my absence
Complete feedback and Student Evaluation Questions (JISC) at the end of the placement
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REMOTE CONSULTATIONS & VIRTUAL TEACHING
The Supervising GP tutors will ensure:
Oversight of all remote patient contacts
Patient consent is recorded in notes prior to starting consultation
As a Student I will:
Respect confidentiality, dignity and the patient’s right to decline or withdraw consent to be seen by a Medical Student
Never personally record any patient teaching or consultations
Never take screenshots of patients, tutors or colleagues
Always use headphones and the QMUL screen background if joining patient consultation or tutorials away from the GP practice.
I confirm that I:
am a member of a defence organisation (MDU or MPS)
have completed the Preparation for Placements online learning module
understand that if I fail to comply with any of the above or act unprofessionally this may result in referral to a Senior Tutor or the Professional Capability Committee
If I have concerns over my placement or supervision, I will try to discuss with my Supervising GP Tutor, or the CBME academic lead Maria Hayfron-Benjamin.
The Medical School undertakes to monitor the implementation of this Agreement and remedy evidence of non-compliance through its quality assurance procedures.
Student Name:
Student (e) Signature:
Date
GP Tutor Name:
GP Tutor (e) Signature:
Practice:
Date
To be signed by each student and emailed to their GP tutor
Please contact Rachel Portelli r.portelli@qmul.ac.uk if you need your GP Tutor’s email
7.5. RESETTLING AND RISK REDUCTION CHECKLIST
Preparing for GP placements in the time of Covid 2021-22
Resettling and Risk Reduction Checklist
WELCOME & WELLBEING - Start by adapting GPs placement to your student(s)
The last 18 months – in particular the pandemic and events triggering the Black Lives Matter movement - have had a complex, and unique, impacts on us all. For our students this meant a sudden switch to online learning, a reduction in direct patient contact and tutor and peer support. Some have cared for or lost loved ones to COVID-19, others have been ill themselves – all have become more aware of health disparities. These factors coupled with lockdowns have affected their learning experience and wellbeing and, in some cases, has led to demotivation and poorer exam results. Students are so looking forward to restarting GP placements but will need help with hybrid and virtual learning or patient contact. Attendance is expected to be 100% (face to face or online as appropriate), less than 90% will require remediation.
Please set aside early time to talk to each student about their experiences, expectations and needs.
Please also use the opportunity to share your experiences over the past year – to build rapport ad compassion
Support students to SPEAK UP if they experience or observe situations that worry them (please see e-Learning for Health online module for supervisors: LISTEN UP
RISK REDUCTION – local arrangements
We have all learned much about reducing COVID 19 transmission and risk of serious illness over the last year. The Medical School has assessed students’ individual risk and introduced a daily rapid Lateral Flow Test before coming to campus. We know each GP practice has developed a local approach based on specific context.
Please a make your practice’s local risk reduction policy is clear to students before they start their placement in person detailing:
LFT Testing requirements
PPE & mask wearing
Ventilation and flow arrangements
Adjustments for the very few students with specifics risks
VACCINATIONS
COVID-19 vaccinations remain voluntary in the UK. The medical school, in line with other institutions, is not compelling students to be vaccinated – but we know the vast majority have had two doses. A very small number may have personal or clinical reasons for not being fully vaccinated. We ask you to accommodate these learners. All students must undertake an online Vaccine Confidence module focusing on individual narratives, and fact verification skills rather than assumed informational deficit.
You can ask students about their vaccination status (we cannot inform you of this)
Accommodate learners who have not completed their vaccination as you would a member of staff – this may mean reducing patient contact
Discuss anxieties and hesitancy without taking a coercive approach
Tell students it is part of their role to support vaccination (regardless of their own status or views)
Please Offer Flu Vaccine (if students are with you in person) - Students are designated essential workers should be treated as staff
Any concerns or questions - Please contact the CBME Module Lead or Administrator.
7.6. END OF PLACEMENT - PROFESSIONALISM ASSESSMENT
Completed via online form – link sent before Day 3 of Placement.
Professionalism Attitude and Conduct Assessment
NOTE: A Professionalism Assessment Form must be completed for all students.
Guidance for GP Tutors
Please inform the administrative lead if there are concerns regarding professionalism.
Feedback should be given to every student about their professionalism during their placement and upon completion of this form.
1) If you are UNCONCERNED about a student's professionalism, an overall assessment of "Satisfactory" may be given without marking "Satisfactory" on every criterion.
2) If you are CONCERNED about a student's professionalism, then THREE or more "Cause for concern" or "Unsatisfactory" in any category results in an overall assessment of "Unsatisfactory".
3) Always indicate and mark an overall "Satisfactory" or "Unsatisfactory" at the bottom of the form.
4) Overall "Unsatisfactory" students are to be REFERRED to their Academic Year Tutor.
5) Please give FULL reasons for any "Cause for concern" or "Unsatisfactory" assessments in the comments box below.
6) The student should make any responses in the comments box below in the online form
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PROFESSIONALISM & CONDACT CRITERIA
EACH ONE IS MARKED USING ONCE OF 4 OPTIONS:
Satisfactory /Cause for Concern/Unsatisfactory/Unable to observe
Honesty and Integrity SATISFACTORY CRITERIA: Always honest with patients, peers, staff and in professional work (presentations, documentation, communication) *
Reliability and Responsibility SATISFACTORY CRITERIA: Reliable and conscientious. Punctual. Completes assigned tasks. Accepts responsibility for errors. *
Respect for Patients SATISFACTORY CRITERIA: Consistently demonstrates respect for patients’ autonomy and dignity. Maintains confidentiality at all times. Always appropriately dressed for clinical setting. *
Respect for Others SATISFACTORY CRITERIA: Shows respect for patients' relatives, other healthcare team professionals and members of staff. *
Attendance and Approach to Learning SATISFACTORY CRITERIA: Full attendance, participation at seminars and other learning opportunities. *
Compassion and Empathy SATISFACTORY CRITERIA: Listens attentively and responds humanely to patients' and relatives' concerns. *
Communication and Collaboration SATISFACTORY CRITERIA: Works cooperatively and communicates effectively with patients and healthcare team members. *
Self-Awareness and Knowledge of Limits SATISFACTORY CRITERIA: Recognises need for guidance and supervision, aware of appropriate professional boundaries. Personal beliefs do not prejudice approach to patients. *
Altruism and Advocacy SATISFACTORY CRITERIA: Adheres to the best interests of patients. *
Health SATISFACTORY CRITERIA: Does not allow his/her health or condition to put patients and others at risk. *
Overall Professional Assessment *
Satisfactory
Unsatisfactory
Please indicate if this assessment has been discussed with the student * This field is required.
Yes / No
GP TUTOR COMMENTS This field is required.
Comments...(free text) Please give FULL reasons for any "Cause for Concern" or "Unsatisfactory" assessments here, you may also make other comments. Please inform the Head of Year and/or Administrative Lead if there are concerns regarding professionalism.
STUDENT COMMENTS
Comments... (free text)
To be signed and dated by both student and tutor
7.7. Novice to expert transition
Gathering information
Learning to ‘take a history’ is a daunting task for some students
Novices tend to be over controlling - they can lose sight of the patient as the managing a lot of information and are eager ‘tick all the boxes’ (especially in the systems review)
Maybe they have seen the history more as an interrogation
They can lose their focus on the patient agenda very quickly as they navigate history taking (the doctor's agenda) and think about the examinations they may need to do
At the same time the conversation has to be purposeful – the questions they ask have to related to the patient’s problems – so they need to BEGIN TO THINK CLINICALLY
Diagnostic hypotheses
Everyone develops a diagnostic hypothesis in 30 secs – (even the old man on the top of the bus) Students should be encouraged to develop hypotheses. They will see their accuracy of their hypothesis increases with expertise
Attending to the patient's agenda
Not just a nice thing to do!
The key to being trusted and appropriate
Being trusted is key to being effective and safe – that is making shared management plan
The generalist contribution is to consider:
Patient may have complex narratives/contexts
There may not be any ‘pathology’ or label possible or needed – there may be ‘illness without disease’
Physical symptoms may be explained by psychological processes (and occasionally the other way round e.g., anxiety in thyrotoxicosis)
Over-diagnosis and over-investigations can lead to HARMS
Things can present very early and in an ‘undifferentiated’ manner – uncertainty is common – but plans can still be made
There may be reasons for the consultation that are not always obvious (to the doctor or the patient)
7.8. Integrated Patient Centered Consultation
The diagram displays the various elements of the consultation, highlighting the importance of going beyond “getting the history” and integrating the medical and patient-specific aspects of the consultation. The shaded boxes are based on the “illness/disease” model proposed by Stewart et al. The bold outlined boxes relate to the tasks and skills defined by Silverman et al in the Cambridge/Calgary observation guide – which forms the basis of most OSCE (Objective Structured Clinical Examinations) exams for undergraduates.
Disease versus Illness These two words are often used interchangeably in the English language but have assumed subtly different meanings which form the basis of the model of the consultation above.
Disease is the medical view of ill-health. It is based mainly on objectively demonstrable changes in the body’s structure or function, and which can be quantified by reference to ‘normal’ physiological measurements. They include, for example, typical symptom clusters (such as, in migraine) abnormal physical findings (e.g., irregular heartbeat), abnormal test results (e.g., raised white cells or TSH in the blood or an enlarged heart on an echo). Disease ‘entities’ (such as Tuberculosis) are assumed to be universal in form, content, clinical findings, natural history, and treatment.
Illness is the subjective response of the patient, and those around him (or her), to being unwell. Particularly how he/she, and they, interpret the origin and significance of this event; how it affects his/her behaviour, and his/her relationships with other people and the steps taken to remedy the situation. It includes both his/her experience of ill-health, and the meanings given to that experience. Illness experience is shaped by how he/she answers the questions listed in Helman’s Explanatory Model (below) and is often expressed in the form of a narrative or personal story.
In most cases people have a disease and an illness at the same time. For example, they may feel unwell – and also have a chest infection. However, in clinical practice it is also possible to encounter ‘disease without illness’ (e.g., asymptomatic diabetes, cancer or HIV infection), and also ‘illness without disease’ (e.g., fearfulness) – but without any discernible physical abnormality. Functional disorders such as irritable bowel syndrome form a sort of hybrid and remember over 20% of all presentations in primary and secondary care remain unexplained. In all cases, difference in interpretations may result in communication difficulties between doctor and patient.