principles, and tools in family medicine

8/3/2019 Principles, And Tools in Family Medicine

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Dr. Adetola OgunbodeD.T.M&H (Liverpool), FWACP (Family Medicine). Consultant

Family Physician, Family MedicineDepartment/G.O.P.D.,U.C.H., Ibadan.

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In 1963, a W.H.O. Expert committee onProfessional and Technical Education of Medical and Auxilliary Personnel noted that“ in every country of the world there

appears to be a dearth of Family Physicians,this applies to all countries irrespective of their stage of development”.

Quote by D. Melessa Philips, M.D, Prof. andChairman of Family Medicine, University of Mississippi Medical Center, Jackson,Mississippi,U.S.A. In a lecture given inU.C.H. in Ibadan (2004).

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U.K.- Family Medicine began in 1966. U.S.A.- 1970.

Nigeria- 1980.

Family Physicians in Nigeria celebrated 25years of Family Medicine in Nigeria, inNovember,2005, at the University of Ibadanconference centre.

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Primary Care: This can be offered by any

health worker, as first contact care.

Family Care: This is care given within thefamily e.g. homecare of malaria.

Primary Health Care: This includesimmunization, health education, water and

sanitation, maternal and child health care,food and nutrition, essential drugs, treatmentof common illnesses and injuries; anderadication of vectors and animal reservoirs.

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o The Family: A groupof people relatedeither biologically,emotionally or

legally. Pequegnat& Bray 1997.

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o Household: A groupof people livingunder the same

roof and eatingfrom the same pot.

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Family medicine is the specialty thatprovides comprehensive andcontinuing healthcare for theindividual, in a holistic manner, within

the context of the family and thecommunity.

The family physician is that primary

care physician who providescontinuous, comprehensive andcoordinated care to the individual andpopulations undifferentiated by age,

sex, disease or organ system.

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A primary care physician is a generalist physician

who provides definitive care to the undifferentiatedpatient at the point of first contact and takescontinuing responsibility for providing the patient'scare.

These physicians function as managers, advocates,educators and counselors for their patients, while

also serving as coordinators of other professionalsinvolved in healthcare.

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1)Comprehensive care

2)Continuing care 3)Coordinated care 4)Committed person-centered

care 5)Community oriented care

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Caregiver.Comprehensive care.

Communicator.

Coordinator.Advocate.

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It is much more important to know what sortof patient has a disease than what sort of disease a patient has.

-Sir William Osler (1904)

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He gives “first contact” care,serving as a point of entry forthe patient into the health caresystem.

◦ He follows a patient-centeredapproach and provides careboth in sickness and in health.

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o Family Medicine includes health maintainanceand preventive care to each family member.

o These preventive services have primary,secondary and tertiary levels.

o For instance,for hypertension which is a non-communicable disease: Primary prevention-Low salt for the populace, Secondary

prevention-Early diagnosis and treatment of hypertension, Tertiary prevention-limitationof complications of hypertension.

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Preventive care:

This is the anticipatory guidance of an individual and/or hisfamily in all health matters through the various stages of an

individual or family cycle.

It involves prospective consideration of the risk factorsrelevant to the variables affecting each individual with respect

to their family history, personality, and environmental factors.

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In summary, comprehensive care offers prompt andquality service for patients regardless of type of illness, age and gender through a biopsychosocialapproach. Identifies undifferentiated problems.

For instance, as a family physician you see patientswith several problems and you have to sort themout, through appropriate treatment and promptreferral.

Cradle to grave.

Includes longitudinal care.

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Offering continuous patient centered healthcare over substantial periods of life, notlimited to one illness episode.

It ensures the continuity of care by followingpatients through the whole of their life-

generational medicine.

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Longitudinal care is based on an on-going exercise involving:

Monitoring: a process which requires a specific set of criteriafor decision making, and the orchestrated measurement of specific parameters to detect changes that are progressingtoward those criteria.

Screening: adapting the periodic screening program conceptsto the individual, based on health risk factor identification.

Early diagnosis based on the application of the problem-solving techniques.

Patient feedback as a tool for keeping the patient cooperativein a relationship perceived as meaningful.

Anticipatory guidance of family cycle demands, psychosocialstresses, and identification of preventive strategies or copingmechanisms.

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The Family Physician uses every opportunitywhich exists for health promotion andpreventive care.

A Family Physician should know about several

things-business, music, the arts and sports.These are reference points that could serve tomake your patient more comfortable.

He listens for the story, looks for cues, touchesand explores the fears, ideas, function andexpectations( FIFE) of the patient in thatencounter.

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Fears- Someone with a chronic

cough fears that he may diesoon.

Ideas- He may feel the illness isdue to the fact that he smokesand that a colleague who alsosmoked died recently.

Function- He is unable tofunction effectively at work.

Expectations- Expects to beinvestigated and given a clean billof heath.

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Serves a coordinative function forhealthcare needs of the patients byinvolving other relevant medical

colleagues.

The Family Physician gives appropriate andtimely referrals.

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Family Physicians understand that theyare integrated into the overall health

care system, working in a defined waywith other health care workers in theprimary, secondary and tertiary levels,

especially as regards early referral andlater follow- up with:

Medical and surgical specialties, nurses,

Physiotherapists, clinical psychologists,

counsellors and dietitians.

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The ideal family physician seeshimself as part of a community-widenetwork of supportive and health careagencies.

All communities have a network of social supports, official and unofficial,

formal and informal. The wordnetwork suggests a coordinatedsystem.

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The family Physician is an advocate onhealth related matters, appropriate use of consultants, health services andcommunity resources. He or she is able toliase with policy makers based onprevalence and incidence of diseases. Forinstance if you notice that people from acommunity are coming down with Typhoid,this could be an indicator of the state of

their water supply. A school with anoutbreak of Chickenpox could be advised toorganize vaccines for the other students.

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The Family Physician is the patient‟sadvocate in the health system.

Advocacy includes ethics- respect,

beneficience, non-maleficience and justice.Defines what is needed to help thepatient with due regard to cost – effectiveness for instance start withaffordable investigations e.g.urinalysis.

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In all parts of the world, resources arelimited - sometimes severely limited. It istherefore, the family physicians'responsibility to manage these resourcesfor the benefit of their patients and for thecommunity as a whole.

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The family Physician is a manager, and musthandle the manpower, facilities andresources-4 m‟s (man, money, materials andminutes) he has available within and outside

the health sector to enable him attain hisgoals effectively.

He must have objectives which are SMART,and should be able to plan, implement andevaluate programmes involved in.

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The family‟s influence on health- FamilySupport:

Emotional support-care and concern.

Esteem support- positive regard for peoplee.g. a couple who have both lost their jobs.

Informative support-giving advice on how toget a job.

Instrumental support-direct assistance e.g.referring to social workers.



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Management of Dysfunctional families.

Following divorce, the Family Physician playsa role in the family, counselling the coupleand the children.

The children –enuresis.The adults have may be depressed or stressed.



Used as a tool in Family Medicine. Provides a focus for understanding the family.

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◦ Systems approach model-Large to small e.g. a jobaccident could be due to biologic factors like lowblood sugar, psychologic factors-poorconcentration, social factors-Brake failure(Machine).

◦

Life-span perspective model-Changes in physicalstamina from childhood to older age.



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◦ Holistic health care model-information andeducation,alternative therapy.

◦ Ethnomedical cultural model. In Purdah-Rickets.

◦ Biopsychosocial model. Biological factors-genetics,

environmental. Psychological factors-FIFE-Feelings, ideas, functions & expectations. Socialfactors- schools, workplace



Family developmental models include, Duvall‟s –Evelyn Duvall, 1977. Stevenson‟s-Joanne Stevenson,1977.

Family Interactional Model Satir‟s –Virginia Satir, 1972.

Structural-Functional Model

Friendman‟s -Marilyn Friedman (1986) Calgary‟s Family Model Systems approach.

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Objective: To determine the basic changes and

developmental tasks common to familiesduring their lifecycle.

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Target: For nuclear families with growingchildren and families experiencing health-

related problems. The stages of family development are marked

by the age of the oldest child, with someoverlapping stages when there are more

children. Health problems: acute illnesses,

malnutrition.

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STAGES

Beginning family

Early childbearing

Families with pre-schoolers

Families with Schoolchildren

Families with Teenagers

Launching centre family

Middle-aged families

Ageing families

8 BASIC FAMILY TASK

Physical maintenance

Allocation of resources

Division of labor

Socialization of members Reproduction, recruitment

and release of members

Maintenance of order

Placement of members in

larger society Maintenance of motivation

and morales



Puts basic tasks and responsibilities of familiesinto four stages:

Family tasks involving maintaining a common household,

rearing children,

and finding satisfying work and leisure.

These tasks also include sustaining appropriatehealth patterns and providing mutual supportand acculturation of family members.

The four stages are delineated by the number of years the couple are married and theirapproximate age.

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- 4 Stages: Emerging family-from marriage for 7 to 10

years

The Crystallizing Family-with teenagechildren

The Interacting Family-children grown and

small grandchildren

The Actualizing Family-Aging couple alone

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The family‟s interactional health dependson its ability to share and understand themember‟s feelings, needs, and behaviorpatterns.

Healthy, nurturing families help theirmembers know themselves throughcommunication of everyday events. Thiscommunication promotes each individual‟s

self-confidence and self-worthy. Satir‟s model of the healthy family consists

of four concepts; self-worth,communication, rules, and links to society.

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Friedman‟s family model was developed fromsociological frameworks and systems theory.

The family is the focus of the model, as itinteracts with suprasystems in the community

and with individual family members in thesubsystem.

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Calgary‟s family model is an integratedconceptual framework of several theorists‟ work that was adapted for nurses at theUniversity of Calgary.

The model is based on three majorcategories:

-family structure,

-function,

-development.

Each of the three categories is furthersubdivided.

Although the family may be examined bylooking at specific parts, each part interacts

with others and changes the whole family3rd August 2009



MEDICAL PROBLEMA couple have being married for 14 years,

but now has a 4 month old baby.

Which model would you use? Developmental model to examine family task and

responsibilities?

Interactional model to focus on family members role?

No definite answer.

Depends on the family.

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Mind-body Medicine-When patients havethings on their mind even if it is in theirsubconscious, they may present with

abdominal pain e.t.c.Psychotherapy, anxiolytics could be given.



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Biopsychosocial Medicine.

Biological-A woman about 55 years withosteoporosis, and also menopausal.

Psychological-hot flushes, always sweating.Social-falls into a gutter, while trying to clean

the sweat off her face, and has a fracture.



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Domestic Violence and abuse.Partner abuse- women are abused more than

men, and it is worse when she is pregnant-because it tells him there will soon be moremouths to feed.

Child abuse-physical abuse, emotionaldeprivation.

Elderly abuse-even neglect by the children canbe an issue.



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Care of the elderly.

Home visits: Is the home safe for the patient,or will it have to be restructured, e.g. showers

rather than bath tubs, a room downstairs,rather than upstairs?



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Care of the dying patient.Palliative Medicine.

As Family Physicians, you will be

involved in the care of the dying

patient, interacting with the family

and helping to cope with grief.



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Care of the terminally ill.Chronic illnesses like cancer, H.I.V.\ AIDS, renal

failure.

Palliative Medicine. Oral morphine.

Hospice- About 6 months left to live.

Domiciliary care-End of life care given in thepatients place of abode.



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Ethics in Family Practice.Every research done in Family Practice must go

through the Ethical Review Board of theinstitution.

Ethics includes verbal consent taken beforeexamining patients, or testing for H.I.V.

( HCT). Written consent is usually taken beforeoffice procedures.



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Ethics in Family Practice.

The principle of beneficience-always do good.

Non- maleficience- do no harm.

Justice and equity.

Confidentiality- keeping your patients secrets

even after the death of the patient.



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Management of communicable diseases.

Surveys in the community.

Notification of diseases to the healthauthorities.

Early detection and treatment.



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Management of non-communicable diseases.

Bariology.

Hypertension.

Diabetes Mellitus.Peptic Ulcer Disease.

These all involve lifestyle modification.



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Lifestyle Modification (HEDWAS)

Health education. Exercise.

Diet.

Weight control and monitoring. Alcohol usage.

Salt.



Empathy and the ability to cope with stress.He or she must be inquisitive and keep

asking the question-why? Research is amust.

Make 6 friends-What? Why? When? Where?Which? How?

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Family genogram Family circle

Family stage

Time line Home visits/House calls

Medical Informatics

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o Family genogram- Also called Family tree or familypedigree or family generational chart. A way of representing the family history using pictures. Avery important tool to a Family Physician, and musthave at least 3 generations. It must be dated. It is

useful in tracing familial disease conditions such asDiabetes mellitus, and can be used in counsellingfor non-communicable diseases e.g. obesity andcommunicable diseases e.g. HIV.

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It includes family hereditarybackground and accompanying risksfactors, major medical, social and

interactional influences- such aslifestyle, dysfunctional families, andhouseholds.

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Title

Three or more generations

The names of all family members

Age or year of birth of all family members Any deaths, including age at\ or date of

death and cause.

Significant diseases or problems of family

members.

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Indication of members living together in thesame household.

Occupations\ schools attended. Dates of marriages and divorces.

A list of the first born of each family to the leftwith siblings listed subsequently to the right.

A key depicting all symbols used.

Symbols selected for simplicity and maximumvisibility.

Date genogram was drawn.

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For quick review of the family situation. To assist medical personel in assessing and

understanding the family quickly, therebyimproving continuing comprehensive care. Builds rapport by using the first names of the

family member and knowing who is living inthe home.

Identifies at a glance significant risk factors infamily members. e.g. diabetes, high bloodpressure.

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Recognises the need for screening in patientswho are at high risk (e.g. frequentmammograms if there is family history of breast cancer).

Promotes life style changes and places

greater emphasis on patient education e.g.discouraging smoking if there is familyhistory of lung cancer and coronary arterydisease.

Demonstrates that family relationships are aconcern of the family physician and importantto the health of each family member.

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It is a circle which shows the emotionalrelationships of a family as depicted by thepatient. The distance from other peoplereflects the degree of emotional attachment

or closeness.

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Family circle- Diagnostic & theraupeutic. Acircle is drawn with the patient in the centre,and other family members, friends and evenpets are plotted inside and outside the circlebased on how close their relationship is withthe patient. It should always be dated, as thesituation may change, as treatmentprogresses.

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5/2/2012 69

Mu

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Dad

Bro-

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Bill

Hus

Eric

son

Wife

Sue

Frie

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ca

t

In

la

ws

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o Timeline-This pre-supposes that certain illnessesare based on events and the period they occur. Forexample, in a patient who has somatic symptomsof 3 years duration, it may be possible to discoverthat he had a major life event at about the same

time.

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o Family Stages-Duval. Stevenson Developmentalmodel:

1)Emerging family-young family, just married.

2)Crystallizing family-Married for about 7-10 years,with young children.

3)Interacting family- teenagers present.

4)Actualizing family-Elderly couple, “empty nestsyndrome”.

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On the increase because of increasing needresulting from shortened hospital stay;increased home care involving intravenousfluids and chemotherapy.

It is used by the Family Physician to develop athorough understanding of their patients andtheir environment, and Family Practiceresidencies encourage house calls in their

training programme (Rakel).

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8Types: 1)The emergency home visit/house call.

2)The acute illness home visit/house call.

3)The chronic illness home visit/house call.

4)The dying patient home visit/house call,

5)The home visit/house call to pronouncedeath.

6)The grief home visit/house call. 7)The home management-versus

hospitalization house call.

8)The home visit house call.

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o Home visits. As a Family Physician ,you would beinvolved in home visits of patients withcommunicable diseases such as Koch disease, forcontact tracing and inspection of the premises.

o It could be done by the Family Physician, with or

without a nurse.

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Home visits: Is the house safe for the seniorcitizen, or will it have to be restructured, e.g.showers rather than bath tubs, a roomdownstairs, rather than upstairs?

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◦

Systems approach model-Large to small e.g. a jobaccident could be due to biologic factors like lowblood sugar, psychologic factors-poorconcentration, social factors-faulty machine.

◦ Life-span perspective model-Changes in physical

stamina from childhood to older age.

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◦

Holistic health care model-information andeducation,alternative therapy.

◦ Ethnomedical cultural model. In Purdah-Rickets.

◦ Biopsychosocial model. Biological factors-genetics,environmental. Psychological factors-FIFE-Feelings, ideas, functions & expectations. Socialfactors- schools, workplace

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Medical Informatics. These involves the useof computers and being internet friendly.

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„From inability to leave well alone; From too much zeal for what is new and

contempt for what is old;

From putting knowledge before wisdom,

science before art, cleverness before commonsense;

From treating patients as cases; and

From making the cure of a disease moregrievous than its endurance,

Good Lord, deliver us.‟

-Sir Robert Hutchison,1871-1960.

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THANK YOU!

principles, and tools in family medicine

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