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CONCEPTS and CHARACTERISTICS CONCEPTS and CHARACTERISTICS OF FAMILY MEDICINEOF FAMILY MEDICINE

Prof. Sulaiman Al-ShammariProfessor of Family Medicine

Department Family and Community MedicineCollege of Medicine

King Saud University, RiyadhIntroductory course fm ,SFH 5 Oct 2015

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Related terms to family medicine• General practitioner (GP)• General practice (GP)• Family physician (FP)• Family medicine (FM)• Family doctor• Primary care• Primary care physician

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Case 1

• Sarah a 24year old teacher. She is married and has two children. She complained of abdominal pain for about three days.

• What are the differential diagnoses?• Where should she seek help?

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Differential Dx of abdominal pain• Food Poisonining• gastritis• menstral period • renal stone • appendicitis • cholicystis • gastric ulcer • IBS • chrone dis • Ischemia • trama • pancrititis • gall stone • Pregnancy • constipation • peptic ulcer • Somatization • Forigne body• Infectuous causes • Tumor

• autoimmune dis • sickle cll crisis• hepatitis• esophagitis• bowel obstruction • ulcerative colitis • hyperparathy roidism • endometrosis • urinary tract infection • cardic angina• abdominal aortic anurism • ectopic preqnancy • Pelvic inflammatory dis• hypocondriasis• panic disorder • intestirel valvulus • musculoskeletal pain • dermtitis • peritonitis

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Definition of Family medicine

Family medicine: Also called family practice. The medical specialty which provides continuing and comprehensive health care for the individual and family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family practice encompasses all ages, both sexes, each organ system, and every disease entity.

( American Academy of Family Physicians)

Concepts of Family MedicineConcepts of Family MedicineDEFINITION:DEFINITION: Family Medicine is a medical specialty of first Family Medicine is a medical specialty of first contact with the patient, devoted to providing, contact with the patient, devoted to providing, preventive, promotive , rehabilitative and curative preventive, promotive , rehabilitative and curative health care, with physical, psychological and social health care, with physical, psychological and social aspects, for the patient, his family and the aspects, for the patient, his family and the community.community.The scope is not limited by system, organ, disease The scope is not limited by system, organ, disease entity, age or sex.entity, age or sex.

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Four Principles of Family Medicine1. The family physician is a skilled clinician. 2. Family Medicine is a community-based

discipline. 3. The family physician is a resource to a

defined practice population. 4. The patient-physician relationship is central to

the role of the family physician.

• The College of Family Physicians of Canada

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Characteristics of general practice/family medicine

• General• Continuous• Comprehensive• Coordinated• Collaborative• Family-oriented• Community-oriented

DRAFT CHARTER FOR GENERAL PRACTICE/FAMILY MEDICINE IN EUROPE , WHO , 1998

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1. Available2. Accessible3. Affordable 4. Acceptable5. Adaptable6. Applicable7. Attainable 8. Appropriate9. Assessable

According to W. Fabb and J. Fry, good primary health care must include the following “As” It must be:

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Influences lead to FM:- Social changes. Specialization. New pattern of illness demanded a new type of physician. Behavioral sciences gave new insights into old problem. Existing disciplines neglect problems encountered in fm.

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Many situations facing the physician are complex combinations of physical and behavioral factors and today’s practitioners are more likely to help patients to achieve equilibrium with their environment.

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Changes in Mortality and Morbidity Successful control of infectious diseases. Emergence of a new pattern of disease.

o Chronic diseases.o Developmental disorders.o Behavioral disorders.o Accidents.o Different infectious diseases.o Increased proportion of elderly.

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Age of Specialization Technology and research lead to specialties and sub-specialties.

Specialist prestige and valuation of technical and research skills over personal care made PHC.

This lead to deterioration of Dr/Pt relationship and malpractice crisis.

Therefore there is need for new kind of generalist.

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New Development in the Behavioral Sciences.Directed attention to:-• Process of seeking medical care.• Aware of physician behavior in decision

making and prescribing.• Doctor-patient relationship.• Behavioral aspect of illness.• Concepts of health, disease and illness.• Role of physician and ethics.FP in key position to integrate these into

practice.

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The changing role of the hospital. Resurgence of care outside hospital particularly at neighborhood.

Balanced of personal continuing care neighborhood with hospital providing support.

Family Medicine as a clinical and Academic Discipline.

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The Principles of Family Medicine FM body of knowledge (facts,

skills, techniques) about problems encountered by FP.

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Principles of FM:-1. FP committed to person rather than

knowledge, diseases or techniques.

2. Commitment open-ended in terms.A. Health problems.B. No defined end point so Dr/Pt

relationship important.

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3. FP seeks to understand illness context (personal, family, social).

4. Every contact is opportunity for prevention or education.

5. Committed to single patients and population whether or not attending HC.

6. Part of community network of supportive and care agencies.

7. Share same habitat as their patients.

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8. See patients at HC, homes and in hospital.

9. Subjective aspects important. FP values, attitudes, feelings determine practice.

10. Manager of resources: Admission, Investigations, Prescription, Referral

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ImplicationsThese principles have implications for

practice:-

1. Continuity of care.2. Comprehensiveness of care.3. Family care.4. Bonding.5. Cumulative knowledge of patient.

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The skills of family medicine1. Solve undifferentiated problems in context

of continuing personal relationship with individuals, families.

2. Preventive skills.

3. Therapeutic skills.

4. Resource management skills.

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The Role of Generalist Have a perspective of the whole organization.

They are communication centers.

Help organization to adapt internal, external changes.

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Misconceptions about the roles of generalist.

1. Cover whole medical knowledge. Fact: specialists, generalists select knowledge needed to fulfill role.

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2. Specialist knows more than generalist. Fact: FP knowledgeable about commonly encounter. Specialists knowledgeable about rare selected by generalists.

3. Specializing eliminate uncertainty. Fact: only way to eliminate uncertainty needs generalist, since problems extend beyond categorical perimeters.

10 Cs of desirable qualities in a family 10 Cs of desirable qualities in a family physicianphysician::

11 = Caring/Compassionate= Caring/Compassionate22 = Clinically Competent= Clinically Competent33 = Cost-effective Care= Cost-effective Care

44 = Continuity of Care= Continuity of Care 55 = Comprehensive Care= Comprehensive Care

66 = Common Problems Management= Common Problems Management77 = Co-ordination of Care= Co-ordination of Care88 = Community-based Care & Research= Community-based Care & Research

99 = Continuing Professional Development= Continuing Professional Development 1010 = Communication & Counseling = Communication & Counseling Skills` with confidentiality Skills` with confidentiality

1.1. C C = CARING= CARING

Caring/Compassionate careCaring/Compassionate care An essential quality in a Family PhysicianAn essential quality in a Family Physician Personal patient centered Care-Personal patient centered Care-

2.2. C = C = CLINICALLYCLINICALLY COMPETENT COMPETENT

Only caring is not enoughOnly caring is not enough

Need for four years training after Need for four years training after graduation and internshipgraduation and internship

3.3. C C = COST- EFFECTIVE= COST- EFFECTIVE

In time and moneyIn time and money

Gate keeper- Use of appropriate resources Gate keeper- Use of appropriate resources

Use of time as a diagnostic toolUse of time as a diagnostic tool

4.4. C C = CONTINUITY = CONTINUITY OF CARE OF CARE

For acute, chronic, from childhood to old For acute, chronic, from childhood to old age, and terminal care patients and those age, and terminal care patients and those requiring rehabilitation.requiring rehabilitation.Preventive care/ Promotion of healthPreventive care/ Promotion of healthCare from cradle to graveCare from cradle to grave

5.5. C C = COMPREHENSIVE = COMPREHENSIVE CARECARE

Responsibility for every problem a Responsibility for every problem a patient presents withpatient presents withPhysical, Psychological & SocialPhysical, Psychological & Social

Holistic approach with triple diagnosisHolistic approach with triple diagnosis

6. 6. C = C = COMMON PROBLEMS COMMON PROBLEMS MANAGEMENT MANAGEMENT

e.g. Hypertension, Diabetes, Asthma, e.g. Hypertension, Diabetes, Asthma, Depression, Anemia, Allergic Rhinitis, Depression, Anemia, Allergic Rhinitis, Urinary Tract InfectionUrinary Tract Infection

Common problems in children and Common problems in children and womenwomen

7.7. C C = CONTINUING = CONTINUING PROFESSIONAL DEVELOPMENT PROFESSIONAL DEVELOPMENT

To keep up-to-dateTo keep up-to-date

Need for breath of knowledgeNeed for breath of knowledge

8.8. C C = CO-ORDINATION= CO-ORDINATION OF CARE OF CARE

Patient’s advocate

Organizing multiple sources of help

9. C = COMMUNITY BASED CARE AND RESEARCH

Care nearer patientsCare nearer patients’’ home home

Preventive, promotive, rehabilitative and curative Preventive, promotive, rehabilitative and curative care in patientcare in patient’’s own environments own environment

Relevant research within the patientRelevant research within the patient’’s own s own surroundingssurroundings

10.10. C = C = COMMUNICATION &COMMUNICATION & COUNSELING SKILLS COUNSELING SKILLS

Essential for compliance of advice and treatment/sharing Essential for compliance of advice and treatment/sharing understandingunderstanding

Confidentiality and safety nettingConfidentiality and safety netting

Needed for patient satisfactionNeeded for patient satisfactionInvolving patient in the managementInvolving patient in the management

Essentials of a Family Medicine Consultation

• Meet & greet• All the components of history, including medication,

personal and Psychosocial with patient centered approach• Summarization• ICE: Ideas, concerns &expectations and effects on patient’s

day to day life & work• Examination/Diagnosis ? Differential diagnosis?/ Red flags• Investigations & Management with patient’s involvement,

safety netting , appropriate F/U & Referral?

Major barriers to equitable health Major barriers to equitable health care - WHOcare - WHO

Unequal access to disease prevention & careRising cost of health care Inefficient health care systemLack of emphasis on Generalists’ (Family Medicine) training

How to overcome these barriers ?

The WHO also states, that the best option to overcome these barriers is to utilize

services of trained Family Physicians

Health outcome indicators Barbra Starfield study confirmed that the central role of

Family Medicine in the health care system of a country results in enhanced quality & cost-effective care .

She proved in a large multicentre study that the health outcome indicators are significantly better in those countries in which Family Medicine plays a central role in the health care system

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Family medicine is well-suited to lead health care reform in this era.

Superior patient outcomes, at a lower total cost, with greater patient satisfaction,

over a wider variety of conditions than other types of medical service.

These values will be appreciated when rationality returns to health care. Until then, family

physicians must work to keep their professionalism and pride intact.

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• Are primary care-oriented• Have more equitable resource distributions• Have government-provided health services or

health insurance• Have little or no private health insurance• Have no or low co-payments for health

services

Overall, countries that achieve better health levels

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Why Is Primary Care Important?

Better health outcomes

Lower costs

Greater equity in health

CONCLUSIONCONCLUSION

Principles of FM have universal application.

Application however, will vary according to circumstances?

The principles and competencies required for the The principles and competencies required for the practice of Family Medicine are universal.practice of Family Medicine are universal.

They are applicable to all cultures and all social They are applicable to all cultures and all social groups, from richest to the poorest in the communitygroups, from richest to the poorest in the community

The Need For Trained Family The Need For Trained Family Physicians Physicians

The central role of a well trained Family Physician in health care is well The central role of a well trained Family Physician in health care is well recognized in:recognized in:

Developed countries -- UK, USA and CanadaDeveloped countries -- UK, USA and Canada Gulf countries ??Gulf countries ?? Developing countries -- ? ? ? ? ?Developing countries -- ? ? ? ? ?

The need is even greater in all less developed countries. The need is even greater in all less developed countries.

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Questions?

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Thank you