Family Medicine Final

Famil C A S E B O y B O O K

O K

CONTENTS

List of family’s recent and continuing illness events

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Cultural and social environment of the family

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Inter-relationships with disease

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Family Genogram

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Sources of Social Support

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Definition of illness

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Dealing with illness in the family and occupancy of sick role page11 Medical and social resources available in the community

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Extent to which household health care needs have been met

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Why needs remain unmet

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How community efforts to prevent disease and promote health Impinge on the family

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Demography, Epidemiology and Psychosocial factors Of illness and disease

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Impact of the student’s presence on the family

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Difficulties and satisfactions encountered

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THE PACE FAMILY Ms. Cettina Pace, a 59 year old female from Cospicua was chosen to be the index case for the purpose of the family casebook. Ms. Pace nee Vassallo is married to Mr. Charles Pace and together with their daughter reside in a ground floor government housing apartment. The casebook interview was conducted at their apartment on the 24th February 2009 and took the format of a discussion. At the start of my interview, I asked the household what they understand by family and who is a member of their family. This question was posed as the elder offspring of Mr. & Mrs. Pace does not reside in the same household. Although the family were disappointed that Roberto (son) had chosen to stop residing in their household, they still considered him an important part of their family. Hence this family, consisting of both parents and their children, is an example of a nuclear family. They explained their desire to be an extended family, by having Cettina’s mother, Lisa reside with them, however due to their small accommodation Lisa had to be institutionalized after the death of her husband George. For completeness’s sake, the third type of family model is the single parent type, where an unmarried, separated or divorced parent lives with his or her children.

FAMILY STORY OF RECENT AND CONTINUING ILLNESSES Cettina has a past medical history of hypercholesterolemia, hypertension, hypothyroidism, depression, sciatica and a past surgical history of hysterectomy, pilonidal sinus removal and hernia repair. Cettina’s daughter, Tiziana complains that although her mother’s flexibility has increased since she started exercising, her mother still finds difficulty in proximal gross movements, like brushing her hair. Her recent sciatica pain has limited her even more. Apart from Cettina, the case index, Charles 58, also suffers from hypertension. Tiziana, 26 suffers from irritable bowel syndrome and Roberto 29 has had no serious illness or disease. In this family, Charles and Roberto are smokers. They have both started smoking at a young age, and Roberto followed his father’s bad habits. The family was not happy Roberto started smoking, especially Cettina; however Charles himself could not stop Roberto from being a smoker when he too was a smoker. Charles is disappointed at the financial burden his habit had on the family. Health wise he believes that it does not affect the family, since he does not smoke indoors.

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CULTURAL AND SOCIAL ENVIRONMENT OF THE FAMILY The family seem to be a very closely knit unit who enjoy each other’s company and the fact that Roberto has left his parents residence without marriage has hurt the family as it is something not usually done in the culture they have been brought up in. It is very evident that the Pace family has close connections with their extended family, especially on Cettina’s side of the family, where a Pace family member visits her mother Lisa at least once a day. This family is also in close contact with her sister Josephine and they frequently visit Freddie, Cettina’s disabled brother, who lives at Dar tal- Providenza. On Charlie’s side, contact between brothers and sisters was greatly reduced when their mother passed away. Apart from the extended family, Cettina trusts “blindly” in her GP, however the rest of her family seem a bit skeptical to this devout trust of Cettina to the GP. Regarding gender-roles within the family, there seems to be division of labor with the house chores shared by both parents and Tiziana too. However, Cettina states that only she is allowed in the kitchen and also claimed to be the main rearer of her children, for who she had quit her job. She is now back on the work bench occupying the role of an executive officer within the public sector. She considers her job to be very common. Charles is a senior auditor who considers himself to have a prestigious job but one that does not give him the authority he would like. Both parents had 11 years of schooling to reach A level standard of education. Their children, both obtained degrees from University with Roberto obtaining a Masters in European Studies. Education gives one acquisition of knowledge and skills that promote health and improved “health literacy”. This family’s educational attainments, occupational status and a parental gross income of approximately €37000, which is shared among the whole family show that this family have a high socio-economic status. This is good news for the family, as an association between socio-economic status and health has been recognized for centuries (Antonovsky, 1967).

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INTER-RELATIONSHIPS WITH HEALTH AND DISEASE Social Class Group I is made up of professionals, Group II of intermediates, Group IIIN of skillednon manual workers, Group IIIM- skilled manual workers, Group IV semi-skilled manual workers and Group V unskilled manual workers. The Pace family falls in group II, since the parents who were the providers of the family fell into this category. Their children are both professionals, and do not depend on their parents any longer, especially Roberto who has moved out of his parents house. During my discussion with the family, they do not seem to agree that their particular social class had any effects on their health. They argued that it depends on who your peers are, and bad habits such as smoking and illicit drug use are common practices within all social groups.

Occupation Regarding their occupations, all the family members argued that their work does not affect health. They argued that there was no exposure to toxic fumes or dust in their occupations. However, when I dug deeper into the matter they did realize that their work could be related to ill health. For example the index case, has suffered tenosynovitis due to keyboard operation. When asked about stress all the family related that their jobs were stressful, and that this stress has caused them an ailment. Cettina for example, at times feels mentally drained and starts to panic, which she describes a trigger to her depression. Recently she had a prospect of promotion in her career, however this extra responsibility and her need to learn new procedures, stressed her so much, that her family gave her advice not to except the post as it was not doing her right health wise. Charles explains how this stress affect the family as a whole, especially since they reside in a small apartment. They are however happy that their jobs are effort- rewarding jobs rather than a demanding control type and they agree that the reward they get is in proportion to their hardwork. This motivates them to work hard.

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Environment They spoke to me about Malta and its polluted, noisy environment as a factor contributing to ill health. It causes them frustration and this frustration together with a day’s stressors results in anger many times within the family, the place they feel most comftable bursting out. Roberto has also suffered from asthma and Tiziana hay fever, which they attribute to the pollution especially in their area, very close to Fgura and Marsa, areas known for pollution.

Accommodation Their small accommodation seems to be their greatest stressor and affects their health the most. They feel they are crowded, and there is lack of privacy. The single desk in the children’s bedroom was not enough for both Roberto and Tiziana to study on and an additional desk was put in the parents’ bedroom for Tiziana to study. They explained how when she was studying, they could not switch on television, and that they had to sleep with lights on and their sleep disturbed by shuffling of papers, drawing of chairs, etc. Roberto states, that the only reason he left home was because he needed his own space. He said that he feels much better now in his rented apartment in St. Julian’s, even though certain luxuries such as having your plate ready and clothes done are now absent.

Neighborhood In addition to the small apartment itself, its neighborhood was no better. They complained about noise, vandalism and theft, which continued to add to their stress and possibly an attribute to Cettina’s depression. However, they are also thankful to some friendly neighbors who helped the family through cooking and cleaning when Cettina fell ill.

Leisure Cettina describes how she recently joined a yoga class and how this has improved her health and quality of life. She described how this active leisure pursuit has enhanced her fitness, and reduced her cholesterol level. Also the family describes that they take daily walks and this not only promotes health but also helps to strengthen their family ties.

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FAMILY GENOGRAM

SOURCES OF SOCIAL SUPPORT page 8

Social support is not important only for assurance of food, warmth and other material resources, but also equally important to provide love, security and other non-material resources that are necessary for normal human development (Berkman & Glass, 2000). Social support is made up of instrumental, emotional and informational support. The Pace family unit in the past used to offer instrumental support to all its members in the form of cash. Since both the children started working, the parents no longer offer instrumental support to their children, who self-support themselves financially. However they still support their children with emotional support and so do the children support their parents emotionally especially Cettina who needs constant moral support. The family seems quite reluctant to gain emotional support from outsiders. Cettina and Tiziana’s informational support come from their sport instructor; however Charles seems to dismiss this information, causing confusion mostly in Cettina who is easily influenced. The family GP is also a source of informational support, especially for Cettina who confides in him and is very dependant and strictly obedient to his orders. The people who provide this social support are the family’s social network. I have realized that this family has a poor social network since they prefer to self support themselves. Cettina is the one who would like the most to expand her social structure but feels constrained by her family who do not approve of this. This poor social network may be a reason for her depression, because a wealth of information indicate that good social support buffers the effects of stressful life events and helps prevent psychiatric disorders (Kawachi and Berckmann, 2001).

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THE DEFINITION OF ILLNESS For the professional, illness is a mechanical process that went bad, one he has to try and fix. However, for the patient, an illness is a life-changing event, not only for himself, but also for his family. The patient may have to change his life-style, give up things he likes, his body image might change. Hence a normal day of a professional may be the life-changing day of the patient and his family. It is easy for a doctor to become immune to the sadness surrounding his job, but he must be careful because he is dealing with a family’s harsh reality and he must not be inhuman. I asked the family to recount an experience of illness that changed their life. They told me about the time when Cettina had her hysterectomy done. They said that their life was disturbed. There was nobody to cook, since this is Cettina’s role. The children were too young to know how to cook and Charles was busy at work and hospital. Cettina felt guilty that this was happening, she felt as if she had neglected her family. She thanks her neighbors and sisters who used to help at times by cooking for the family and see to her children. She found that spirituality also helped her pass through this difficult time. At the same time, the children were worried and confused about what was going on.

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DEALING WITH ILLNESS AND THE OCUPANCY OF THE SICK ROLE The family undergo regular check-ups and encourage and support each other to keep doctor appointments. Nobody goes alone to the doctor, the patient is always supported. The next step to deal with an illness is to accept this new state, and not only take the medications required but also to change your lifestyle. This includes a change in diet, where Cettina prepares low salt and cholesterol diets for her family and avoids certain foods that upset Tiziana’s gut due to her irritable bowel syndrome. The whole family goes for walks. Tiziana also likes to read on the internet about her family’s illnesses and conditions to be more informed and this helps her to deal with her family’s illnesses. When Cettina said that she felt guilty that she is always sick, this caused a stir in the rest of the family members. They told her that with the occupancy of the sick role one is exempt from responsibility for the incapacity since it is beyond the sick person’s control. This implies that she is exempt from her normal tasks and roles for the duration of the illness and hence Cettina should never feel guilty when she occupies the sick role. However they did add that as an occupant of the sick role, Cettina is duty bound to recognize that being ill is inherently undesirable, and that she has an obligation to try and get well. Another duty of the sick person, according to this family is to seek competent help and to cooperate in the process of getting well.

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LIST THE MEDICAL AND SOCIAL RESOURCES AVAILABLE IN THE COMMUNITY •

Health Centres or Private GPs

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Hospital: Outpatients Appointments for checkups regarding state of chronic diseases such as hypertension, hypercholesterolemia, hypothyroidism, colonoscopy screening and follow up with consultation.

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Accident and emergency department: for acute conditions

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Hospital in-patient

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Pharmaceutical services and free medications (Schedule V and the pink card)

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Community nursing and midwifery service

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Immunisation services

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Speech and Language Department

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Child Development and Assessment Unit

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Support Line 179

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Adolescent Outreach

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Programm Ulied Darna

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Social Housing Department

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Other Institutions e.g., Hospice, Caritas, Sedqa, Meals on Wheels, Appogg, Richmond’s foundation.

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A number of support groups e.g. for diabetics, alcoholics, help to quit smoking.

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A number of institutional homes, for the elderly and disabled.

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HAVE THE FAMILY HEALTH CARE NEEDS BEEN MET BY THE AVAILABLE RESOURCES? Cettina, the case index has a very good relationship with her general practitioner, and has been using the same GP as long as she can remember. Cettina states that she will never change her GP as he knows not only her past medical, social and family history, but he has also developed a good friendly relationship with her. She cannot understand why her family keeps on insisting she needs second opinions on certain issues when her GP surely knows it all the best way. Cettina also gets support from her psychiatrist regarding her depression. She explains how tough it is to open up to this new doctor, especially regarding these problems which are a bit of a taboo. Her family however does not understand her feelings, they argue that the doctor is not a friend; the doctor is a professional and opening up to any doctor should be as easy. They also make use of the outpatients department for check-up appointments regarding their chronic conditions, however they complain about the bad service, and prefer private clinics, as they trust them better. The family is entitled to free medications for anti-hypertensive and cholesterollowering drugs under the regulations of Schedule V, and they are very grateful as it is very helpful financially. The family also makes use of the community nurse. The nurse explains to the family, how Charles should prepare himself for colonoscopy. The family also made use of Hospice, when Cettina’s father was dying with prostate cancer. The family also needed the resources of Caritas when their son was caught in possession of illicit drugs. They also needed to use the service of the Bormla home for the elderly for Cettina’s mum, since they did not have space to keep her at their place and Dar talProvidenza, for Freddie, Cettina’s brother.

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Why needs remain unmet Cettina clearly needs more help regarding her depression and her psychiatrist does not seem to be helping her enough, partly due to her lack of trust in him and her envisagement of her condition as a taboo. An association, for example the Richmond’s foundation would be of great help to her. Her thyroid problem, however, makes her lethargic and she finds it hard to cope with her life already, and she argues that she cannot cope with another activity in her life. Also, it would be very helpful for a directory of all the medical and social services available in Malta to exist. Charles suggested that it would be a very good idea if a child care centre existed for the children of those who have a sick parent or a parent in hospital.

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HOW THE EFFORTS OF THE COMMUNITY TO PREVENT DISEASE AND PROMOTE HEALTH IMPINGE ON THE FAMILY The health promotion department does a very good job according to this family. Charles say that the promotional material do have potential to influence people, but he himself has no will to change, and no anti-smoking promotional material will make him quit smoking. The family appreciated the effort of the health promotion department and the variety of media it uses for promotion, but they all agreed that a television advert is the most effective.

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DEMOGRAPHY, EPIDEMIOLOGY AND PSYCHOSOCIAL FACTORS OF ILLNESS AND DISEASE

HYPOTHYROIDISM Hypothyroidism is more common in woman, with 1.5- 2% of woman suffering from this diseases. The incidence of hypothyroidism increases with age: among persons older than 60 years of age 6% of women have laboratory evidence of hypothyroidism where TSH levels are twice normal (Ferri: Ferri’s clinical advisor 2009, 1st ed). Patients of Caucasian origin as my case study is are more affected than people of black descent. Cettina had no previous family history of the disease and no associated autoimmune disease. The hypercholesterolemia experienced by Cettina is most probably due to her ongoing hypothyroid disease. Depression is one of the major symptoms associated with hypothyroidism. Haggerty states that 100% of patients presenting with severe hypothyroidism are found to have concurrent depression as was the case of the index patient (Borderline Hypothyroidism and depression, Haggerty JJ & Prange AJ, 1995). The biopsycosocial model represents a health concept. It depicts a treatment paradigm that acknowledges the contribution of biological, psychological and social factors (The need for a new medical model: a challenge for biomedicine, Engel, 1972). Hypothyroid has been successfully treated in many cases by the biomedical treatment such as drugs. For example, Cettina’s hypothyroid is well controlled from her levels of TSH and T3 and T4. However, symptoms sometimes seem to recur even if she is well controlled. This has been well documented in the literature (The diagnosis and management of hypothyroidism, Roberts CGP & Ladeson PW). If psychological and social factors are also dealt with, this chronic condition will be dealt with in a much better way, and may control the disease better than with merely the biomedical model of treatment (The biopsychosocial model and hypothyroidism, B.T. Brown et al., 2005).

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HYPERTENSION Hypertension is also a disease that increases in its prevalence with age, and this time the races of African descent have a higher prevalence f hypertension than the Caucasian race. A few other personal characteristics influence hypertension. These include concurrent diagnosis of diabetes mellitus, the presence of obesity, lack of physical activity(present in this family before the diagnosis of hypertension) and excessive use of sodium and alcohol (The prevalence and demographics of hypertension, Davidyan, A). Lisa, Cettina’s mother also suffered from hypertension, as seen in the genogram. In the case of Charles, his father Francis and brother Joe have also suffered from hypertension. The genetic factors contributing to hypertension have not yet been found. The role of psychosocial factors such as: type A behavior, depression and anxiety, are well documented in the etiology of hypertension (Circulation, Krantz DS et al, 1987). However there are some conflicting studies (The relationship of psychosocial factors to coronary artery disease in Framingham study I: methods and risk factors, Haynes CG et al, 1978). Biologically it is plausible that psychosocial factors may interact with hypertension. Stress may activate the sympathetic nervous system, leading to increased cardiac output, vasoconstriction, arterial pressure elevation, impaired endothelial faction and platelet activation (Effects on psychological and social factors on organic disease: a critical assessment of research on coronary heart disease, Krantz DS, 2002).

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EVALUATION

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THE STUDENT’S INFLUENCE ON THE FAMILY Cettina Pace is my mum’s sister, and hence I am part of their extended family. As I have already said, the Pace family especially Cettina are very close to their extended family, hence during the interview we were discussing things as if we were talking normally, and they definitely did not feel like they were put in any uncomftable or unnatural situation. During my interview, I believe I made them more aware that health is not just the absence of disease, but as the World Health Organization describe it: ‘a state of complete physical, mental and social well being’.

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DIFFICULTIES AND SATISFACTIONS ENCOUNTERED I felt quite uncomftable asking Cettina about her mental health condition, which for her is a taboo, and rarely mentioned even in the family. The satisfactions were plenty: I was well accepted in the family, and they tried their very best to help me with all the information I needed. During the preparation for the interview, I realized, that there was much more to family medicine than just the biomedical model of curing a disease, and that the biopsychosocial factor was much more relevant. In order to treat the chronic conditions with this model, the case index should be asked questions that point to his and his family’s biopsychosocial being.

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