INTRODUCTION TOFAMILY MEDICINE.

• Contents:• 1. Definition• 2. Brief History• 3. The 4 Cs & 4 Ps of Family Medicine• 4. Why Primary Care?

DEFINITION OF FAMILY MEDICINE

• FAMILY MEDICINE/FAMILY PRACTICE/ GENERAL PRACTICE is a medical specialty/component of the health care

system that provides - initial, continuing, comprehensive & coordinated medical care - for all individuals, families & communities - which integrates current biomedical, psychological & social understanding of health. RACGP definition.

FAMILY MEDICINE

• It provides medical care across all ages, sexes, diseases & parts of the body.

• Based on knowledge of the patient in context of the family & community.

• Emphasizing on disease prevention & health promotion.

• The main objective is to deliver primary health care.

PRIMARY HEALTH CARE

Primary care is that care provided by physicians specially trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom or health concern (`the undifferentiated’ patient) not limited by problem origin (biological, behavioral @ social), organ system or diagnosis.

PRIMARY CARE

• Primary Care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis & treatment of acute care & chronic illnesses in a variety of health care settings (e.g. Office, inpatient, critical care, long-term care, home care, daycare etc.)

• Primary care is performed & managed by a personal physician often collaborating with other health professionals, & utilizing consultation @ referral as appropriate.

PRIMARY CARE

• Primary care providers aim to accomplish cost-effective care for the patient by coordination of health care services.

• Primary care promotes effective communication with patients & encourages the role of the patient as a partner in health care.

(AAFP definition.)The terms Primary Care & Family Medicine are NOT

interchangeable.

SECONDARY CARE

Service provided by medical specialists who generally do not have first contact with patients

eg . Surgeons,orthopaedic specialists, gynaecologists.

TERTIARY CARE

• Specialist consultative care,( usually on referral from Primary @ Secondary medical care provider ) by specialists working in a centre that has personnel & facilities for special Ix.& Rx.

• Eg. Oncology, Burns Centre, Neurosurgery.

BRIEF HX. OF FAMILY MEDICINEBefore late 19th century, FM was the only kind of medicine and most physicians

were Generalists.Advancement of modern scientific and technological medicine ----------------------

subspecialties ( hospital based )Specialization gained momentum with:- 1910 : Flexner Report ( U.S ) recommended that research, inpatient teaching

& consultant care should become the essence of medical education.Medical schools stopped training generalists ------------ increase specialists &

reduction in general physicians, restricting the community’s access to a family physician & increased healthcare cost.

Addressing the demand for high quality, cost-effective care & the provision of continuity of care for the chronic diseases of the aging population, American Medical Association appointed 2 committees which produced 2 reports:

1. Millis Report 2. Report of the Willard Committee

• Both recommended:• The need for the Primary Physician of first contact

who delivers continuous and comprehensive healthcare.

• The creation for the specialty of family practice.• Training by medical schools.• 1969: American Board of Family Practice

established.• 1973: The College of GPs of Malaysia.(AFPM)

The 4 Cs & 4Ps of FM.

4Cs• Community Orientation.

• Continuity of Care.

• Comprehensive Care.

• Coordination of Care.

4Ps• Primary @ First Contact

Care.• Personalized Care.

• Preventive Care.

• Patient Oriented Care.

Community Orientation.

• Practice environment is the community.• Exposed to the diseases and problems of that

community.• Sensitive to the culture of the community.

Comparison between General/Community Practice and Hospital Practice.

GENERAL PRACTICE• PATIENT-Person, Ambulent.• PHYSICIAN-Friend,

Improvise, Peer. Sensitive to the community, 1 generalist discipline, Cares for a broad range of

problems, Deals with pt.- oriented

problems.

HOSPITAL PRACTICE• PATIENT- Patient,Dependent• PHYSICIAN-Official, Follows

Procedure, Hierarchical,

• Isolated from Community. Multiple Narrow Disciplines, Cares for specific problems,

Deals with pathology -oriented problems.

GENERAL PRACTICE VS HOSPITAL PRACTICEGP

• DR.-PT. RELATIONSHIP Continuing, Based on Trust, Persuasive, Sees indv. as member of a family, Culture specific.

HOSPITAL

• DR.-PT. RELATIONSHIP Episodic, Dominant, Authoritarian, Sees indv. as member of the public, Culture neutral.

CONTINUITY OF CARE• Caring for pt. from the first contact into the health care

system.• From prenatal till old age.• Caring for pt. in sickness & in health.• Initial care, emergency care, episodes of illness, long-term

care of chronic diseases, advice & counseling, rehabilitation and palliative care.

• (Palliative Care – Active total care of pts. whose disease is not responsive to curative rx.

----------the aim of care is to achieve the best Q of life for the pts. & families.)

COMPREHENSIVE CARE

• Provision of a wide variety of services, covering the majority of the pt.’s needs.

• Convenient to the pt. as pt. doesn't need to go to multiple providers for their health care.

• 85-90% of pts. who presented to a FP are managed without referral.

• Accepting responsibility for organizing care for the individual total health needs.

COMPREHENSIVE CARE

• Includes - Maintenance of Health - Prevention of Disease Whole Person Care – seeing individual as a whole

person. Takes into consideration the social, economic &

psychological factors affecting the individual & the organic pathology.

Appropriate referral. Coordinates patient’s care.

COORDINATION OF CARE

• The capacity to act as coordinator of all health resources needed in the care of the patient.

• The FP must: - have a realistic overview of the pt’s problems - be aware of the variety of services available - select the one that is most appropriate - taking into account pt’s background, personality,

fears & expectations

COORDINATION OF CARE

• The FP must also - collect & interpret results of studies & referrals - help pt comprehend what is happening to him.

PRIMARY @ FIRST CONTACT CARE

• FP is the point of first contact , the point of entry of the pt into the health care system.

• FP provides definitive care to the ill-defined, undiagnosed pts. – the undifferentiated pts.

• Deals with problem complexes rather than established disease.

• FP makes total assessment of the pt’s condition without subjecting pt to unnecessary Ix., procedure & Rx.

Many reasons for the 1st presentation:

• Symptoms @ signs• Health advice • Prevention @ health promotion• Emergency care • Psychological @ emotional problems• Sometimes the reason for the visit is not what

the pt c/o – HIDDEN AGENDA, thus making the pt. unsatisfied with the FP’s explanation.

PERSONALISED CARE

• Refers to the unique interaction between the pt & the physician.

• FP sees the pt as an indv. with a healthcare need; not merely giving an episodic care of a presenting complaint.

• FP sees the pt many times over a long period of time.• During this period, a comfortable & trusting

relationship is developed.• Many problems are addressed gradually over many

visits.

PERSONALISED CARE• Decision making is shared between the FP & the pt. • The FP develops close relationship with the pt’s family & sees

each member grows into the different phases & roles of his/her life.

• A FP also appreciates the complex mix of physical, emotional & social elements in pt care.

• Tumulty (1970): Pts. consider a good physician to be one who shows genuine

interest in them, thoroughly evaluates their problems, demonstrate compassion, understanding & warmth & provides clear insight into what is wrong & what must be done to correct it.

PREVENTIVE CARE

• Means of promoting & maintaining health @ averting illness.

• Involves the removal @ reduction of risks, early diagnosis, early treatment, limiting complication & maximising adaptation to disability.

• Primary P – Actions taken to avert the occurrence of disease.

• Secondary P-To stop @ delay the progression of D• Tertiary P – Mx of established D so as to minimise

disability ( Rehabilitation)

PREVENTIVE CARE ACTIVITIES

• Prenatal counseling• Well baby check• RME -pre-employment -pre-sports

participation• Before international

travel counseling

• Smoking Cessation Clinic

• Immunization• Prescribing aspirin to

CAD pts.• Post stroke

rehabilitation• Obesity Clinic

PATIENT ORIENTED CARE• Whole person approach to Mx.• Different from Disease Oriented Care - Hx-Phy.exam-Ix-Dx-Rx the Disease. - Defined in terms of pathology. - No signif.focus on feelings of pt suff.fr.dis.• Views pt from a broad perspective.• Takes into account Physiology, Physical Illness, Emotional

Health, Social, Occupational & Environment – the BIOPSYCHOSOCIAL approach.

• Why pt oriented care? Why BPS approach?

The Family’s Influence On Health

• Family relationships, dynamics & social supports are strongly related to healthy indv. Functioning.

• Positive relationships support health functioning.

• Negative relationships contributes to stress & adverse health outcomes.

Psychosocial Influences On Health

• Knowledge, attitudes, beliefs, emotions, relationships & social environment interact to affect the experience of illness @ well-being.

• Work, school, home, social support network, financial resources are factors that affect health.

• Addressing any of these can positively affect functioning.

• FP can work with pt to reduce stress & mobilize social support resources.

WHY PRIMARY CARE?• Primary Care vs. Subspecialty Care:• Analysis of 15 y data fr. all 50 states of USA by Barbara Starfield

& colegues at John Hopkins U School of PH concluded:• The higher the ratio of PCP to SS, the better the outcome: - all-cause mortality, infant mortality, low birth wt, life expectancy, self-rated health……………. The greater the no. of PCP, the lower the mortality, the greater

the no. of subspecialist to population ratio, the higher the mortality.

WHY PRIMARY CARE• Subspecialist-focused care tends to lead to higher costs & poorer outcomes.• REASONS:• When pts have PCP as the regular source of care – Preventive services more consistently delivered. Chronic diseases are better mx. Ac.problems diagnosed & treated early. Lower income gp – greater access to care. PCP active at community level to improve health care

resources & attitudes of both healthy pt & pt with chr. dis. Pt who goes to a variety of subspecialists without having a PCP, their care

tends to be fragmented & discontinous. Rx.focused on 1 body system can have adverse impacts on other areas.

One third of the excessive cost is attributed to performance of unnecessary procedure.

• A FP, because of the ongoing relationship with his pt is less under pressure to exclude diagnostic possibilities by use of expensive lab & radiologic procedures than the subspecialist who is unfamiliar with the pt.

THE END. Hope you appreciate your exposure in the Primary Care posting.

Ref:

• Rakel Textbook of FM-7th edition.• Essentials of FM-5th edition.• John Murtagh’s GP-4th edition.• The Emergence of Family Practice-MK

Rajakumar.