Family-medicine-in-a-nutshell.pdf

Family Medicine

Foundation Courses for the FM Residency Training Programs in the Philippines

Academic Domains 1 

2  3  4  5  6  7 

Family Medicine Principles and Practice Primary and Secondary Care Acute Care Preventive and Wellness Communication and Relational Skills COPC Occupational Health and Safety

8 9 10 11

EBM QA Research Information Technology

12. Medical Ethics and Professionalism 13. Legislation on Health and the Family 14. Practice Management and Health Administration 15. Hospice and Palliatve Care

1. FAMILY MEDICINE PRINCIPLES AND FAMILY PRACTICE

FAMILY MEDICINE PRINCIPLES AND FAMILY PRACTICE › Viewpoints

of

the family › Family Structure › Basic Areas of Family Function › Family Life Cycle › Family as a Unit of Care

According to the United Nations: ›  Family

is

..a group of people related by blood, marriages or adoption, which live together in one household.

Viewpoints of the Family Sociologic Enduring social form in which a person is incorporated

Biologic

Psychologic

Genetic transmission unit

Matrix of personality development

The Family as the Unit of Care › Family means_

Health Care

›  taking

care of all individuals in the family on a one by one basis,

›  dealing

with the family as object of management

›  influencing

family members to change factors affecting each individual’s health

Incorporating FAMILY SYSTEMS theory into CLINICAL PRACTICE Step 1: Recognize Family Structure Step 2: Understand Normal Family Function Step 3: Learn to Assess Family Structure and Function in Clinical Practice

FAMILY STRUCTURE

Family Structure Nuclear

Extended

Single Parent

Blended

BASIC AREAS of FAMILY FUNCTIONS

Biologic Economic

• Reproduction / Child Rearing • Nutrition / Health Maintenance / Recreation

• Financial Resources / Allocation • Financial Security

Educational

• Teach values and inculcate attitude • Model skills relating to other functions

Psychologic

• Natural development of personalities • Building healthy relationships • Optimum psychological protection

Sociocultural

• Socialization of children • Promotion of status and legitimacy

CHARACTERISTICS!

typical Filipino Family ›  Closely

knit ›  Bilaterally extended ›  Strong family orientation ›  Authority is based on seniority/age ›  Externally patriarchal, internally matriarchal ›  High value on education of members ›  Predominantly Catholic (80%) of population ›  Child-centered ›  Average number of members is 5 (NEDA Statistics) ›  Environmental stresses: economic, political, urbanization and industrialization, health problems

The Family as the Unit of Care 1. The Family as the _Social ›  ›  ›  ›  › 

Context for Health Care

Transmission of infectious / communicable diseases Health behaviour requirement in the unit Resource utilization / source of support Health and illness definition Health decision / approaches and strategies

2. The Patient’s

Problem

_is the Family’s Problem à 

Important ways in which the family plays a role in the health of its members (Doherty and McCubbin, 1985):

› 

Health promotion / maintenance and illness / injury prevention Coping with stressful life events Family based health and illness appraisal Family interaction and level of functioning in response to support specific illness Help seeking or deciding on the issue of seeking medical support Family adaptation / coping with illness including care giving, strict adherence to prescribe treatment and lifestyle modification

›  ›  ›  ›  › 

3. The Family is the Greatest in the Patient’s Treatment ›  90%

Ally

of cases are ambulatory / out-patient consultations with home confinement / prescriptions

Family Strengths ›  The

ability to provide for the family’s

needs

›  physical,

emotional, spiritual, cultural

›  Child-rearing

practices and discipline

› Communication ›  verbally

and non- verbally

› Support,

security, encouragement

4. Presence of the Family in the Interview or Consultation ›  Family’s

influence on the patient’s personality, values, beliefs and experiences ›  Family’s shared views on clinical decisions ›  The patient and his family’s respect towards physician’s clinical expertise and merits

Family Strengths ›  Growth-producing ›  Self-help

Relationships

and accepting help

› Flexibility of family functions and roles ›  Crisis

as a means of growth

›  Unity

›  Family

and support during hard times

unity, Loyalty and intra-family

Cooperation

The value of the ‘Family ›  Health

as a Unit Care’

problems as isolated phenomena can neither be understood nor successfully dealt with

›  Treatment

as a unit yields more certain a complete diagnosis, better medical outcome and benefits with regard to prevention

Step 1: Recognize Family Structure

Step 2: Understanding Normal Family Function

Step 3: Learn to Assess Family Structure and Function in Clinical Practice

FM TOOLS

Utilizing _the SYSTEMS APPROACH in Family Practice

STEP 1: RECOGNIZE FAMILY STRUCTURE ›  › 

To know the individuals in the family The following information should be obtained: Names of the individual family members 2.  Place of residence 3.  Specific roles in the family 4.  Stage of the family in the family life cycle 5.  Significant dates in the family (marriage, birth, death, etc.) A good way to obtain and record this information about the family structure is to include a wellstructured FAMILY GENOGRAM for each patient 1. 

YAP - ZALES FAMILY Alvin, 50 Mheilchie, 23

Crisantal, 4

Marichu, 38

Eden, 23 Alma Rose, 19 Marvin,18 Rhea, 11Mark, 9

Christian, 1 YAP- ZALES April 18, 2015

I

Alvin, 50

Marichu, 38

II Mheilchie, 23 III Crisanta, 4

Eden, 23

Alma Rose, 19 Marvin, 18 Rhea, Mark, 9 11 Very close Distant

Christian, 1

Close

Conflictual

STEP 2: UNDERSTANDING NORMAL FAMILY FUNCTION The five basic functions by all families are_ 1.  Families provide support to each other 2.  Families establish autonomy and independence for each person in the system, which enhance personal growth of individuals within the family 3.  Families create rules that govern the conduct of the family and of the individuals within the family 4.  Families adapt to change in the environment • 

• 

5. 

First order change involves adaptation to environment change that requires minimal change in the family structure Second order change involves fundamental change in the family structure

Families communicate with each other

FIRM RULES Normal Families

RIGID STRUCTURED

DISENGAGED SUPPORT & CONNECTED AUTONOMY & SEPARATED ENMESHED FAMILY INDIVIDUATION FLEXIBLE

CLOSENESS

CHAOTIC

ADAPTABILITY MODIFIED TWO-DIMENSIONAL MODEL OF FAMILY FUNCTION Normal families tend to fall within the shaded circle

The Cycle of Family Function

Adaptation [Coping] (5) Resources Adequate (4) Resources Inadequate (6) Crisis (7) Maladaptation

Family in Functional Equilibrium (1)

(Functional or nurturing)

Stressful Life Event (2)

Family in Disequilibrium (3)

Extra-Familial resources (8)

Pathologic Defense Mechanism (9) Terminal Disequilibrium (12)

Pathologic Disequilibrium (10)

SMILKSTEIN’S CYCLE OF FAMILY FUNCTION A model for family response to stressful events

Stressful Life Event (1)

CHECKLIST TO ASSESS FAMILY FUNCTION 1.  2.  3.  4.  5.  6.  7.  8.  9.  10. 

How many are there in the family? Who lives at home? In what phase of Family Life Cycle is the family? What problems do this phase raise for them? What major problems has the family had in the past? Does the family feel these problems were dealt with satisfactorily? Is there any history of alcoholism, drug abuse or dependency? How are major decisions made in the family & by whom? Are the in-laws & relatives helpful? Do they create problems for the family? Do the family members have many friends in the neighborhood? To what groups or clubs do family members belong?

CHECKLIST TO ASSESS FAMILY FUNCTION 11.  12.  13.  14.  15.  16.  17.  18. 

What community resources has the family used? Would the members use them again? Has this family not used community resources at times when they would have been appropriate? What does each parent expect of each child, both on day to day basis & for the future? What does each member of the family have to do to get attention? How much tolerance for individual differences is there in the family? What are the goals, interests, and values of the family? Do all the family members work together toward these goals? What is the educational level & financial status of the parents?

STEP 3: LEARN TO ASSESS FAMILY STRUCTURE AND FUNCTION IN CLINICAL PRACTICE › 

Meeting the family as a unit has become the standard medical practice in the context of patient with: ›  ›  › 

› 

Life-threatening ailment Chronic illness Ensuing death

Family assessment tools help the family physician in convening families

Family Assessment Tools/Instruments I.  II.  III.  IV.  V.  VI.  VII.  VIII.  IX.  X. 

Family Genogram Family Circle Family APGAR by Smilkstein FACES (Family Adaptability and Cohesion Evaluation Scale) FES (Family Environment Scale) by Moos Clinical Biography and Life Events SCREEM (Social, Cultural, Religious, Economic, Educational and Medical) DRAFT (Draw-a-Family Test) Family Assessment Model Family Mapping

I. Family Genogram › 

Advantages, uses and information derived: o  o  o  o  o 

› 

Records names and roles of each member Separates extended family into several households Documents medical problems of each member of the family Documents significant dates in the family history Reveals more subtle information about the family

Disadvantages: o  o 

Limited role in assessing family functions Time consuming to prepare and complete

II. Family Circle › Described

by Thrower, et al › A family assessment technique whereby a physician presents a large circle to an individual or group of individuals with the following instructions: “Draw in smaller circles to represent yourself and all the people important to you- family and others. Remember, people can be inside, in touch and far away. They can be large or small on their significance or influence. If there are other people important enough in your life to be in your circle, put them in. Initial each circle for identification”

Family Circle Advantages

›  ›  › 

While being done, the family physician can see another patient Actual assessment occurs when the patient himself explains his diagram

Disadvantages

›  › 

Difficulty in standardizing and interpreting

Family Circle Ches ter Gina Tita c i Mav

Ate Wal ter

Vi

Chiq ui

III. Family APGAR › 

An assessment tool originally described by Smilkstein which is applied in basic situations like 1.  2.  3.  4. 

›  › 

In direct involvement in patient care In providing information while patient is being treated In a family crisis, and in Psychosocial problems

A rapid screening instrument for family dysfunction Measures the individual’s level of satisfaction about family relationship

Family APGAR A – Adaptation:

- capability of the family to utilize and share resources which are either intrafamilial or extrafamilial

P – Partnership:

- sharing of decision making

- measures satisfaction attained in solving problems

G – Growth:

- physical and emotional growth

- measures satisfaction of the available freedom to change

A – Affection:

- how emotions like love, anger and hatred are shared - measures the members’ satisfaction with the intimacy and emotional interaction that exist

R – Resolve:

- how time, space and money are shared - measures satisfaction with the commitment made by other members

FAMILY APGAR Almost always

APGAR QUESTIONNAIRE

Some of the Time

Hardly Ever

I am satisfied that I can turn to my family for help when something is troubling me. I am satisfied with the way my family talks over things with me and shares problems with me. I am satisfied that my family accepts and supports my wishes to take on new activities and directions. I am satisfied with the way my family expresses affection and responds to my emotions I am satisfied with the way my family and I share time together.

Total the points according to the following: scheme Almost always 2 points Some of the time 1 point Hardly ever 0 point

Then add up the points and interpret as to the following: 8 – 10 pts Highly functional 4 – 7 pts Moderately dysfunctional 0 – 3 pts Severely dysfunctional family

IV. FACES

Family Adaptability And Cohesion Evaluation Scale › A

SELF-REPORTED SCALE wherein the patient rates his or her family based on Olson’s circumflex model of family function using 30 items on 1 to 5 scale

V. Family Environment Scale [FES]

›  Consists

of a 90-item questionnaire prepared by Moos

›  Used

as a research tool to compare health care resources with family variables

VI. Clinical Biographies and Life Chart › Valuable

tools which can facilitate analysis of connection between a person’s experiences of health and illness to his personal life.

VII. SCREEM

Social, Cultural, Religious, Economic, Educational, Medical ›  Assesses

the family as to the capacity to participate in the provision of health care or to cope with crisis ›  Each part of the acronym is considered in terms of resources and pathology

VIII. D.R.A.F.T. Draw-A-Family Test

› 

Designed by Dr. R. Cruz and Dr. Alex Pineda Jr.

› 

A simple, practical and cost effective tool for assessing family functions; a projective technique that can be administered individually or in groups

› 

Purpose: to gain more insights into family situations in order to have a better understanding of the nature of the problems

› 

The family is seated around a table and are provided with a blank, clean, unruled bond paper and lead pencil with eraser and asked to draw their family

Draw-A-Family Test Ø 

Ø 

Does not measure the person’s inherent ability to draw but how he pictures his family members The following are important in the evaluation and interpretation: 1.  2.  3.  4. 

Ø 

Configuration of the father, mother, siblings Sequence of succession Quality of lines Significant details like omission of some parts

Advantage: Identifying the possible risk factors that are present in each family member

IX. Family Assessment Model 1. Family

Identification

A. Composition: Who are the family members

currently living in the household? Are they kin or non-kin? What are their ages? B. Social History: What is the social background of each member regarding education, income, occupation, marital status, ethnicity and cultural? C. Community & Neighborhood: What is the general tone of the neighborhood? Are resources such as water, electricity, and sewers available? Is the area one of the affluence or poverty? What are the residents of the neighborhood like (e.g. friendly, non-committal)?

Family Assessment Model 2. Individual and Family Data A. Health History

B. Family Dynamics – dysfunction in the family dynamics is often reflected in the health status of the family as a whole and of individual members

›  › 

Developed by Salvador Minuchin, a Psychiatrist-Family Therapist Facilitates the communication of informations about a family system to colleagues so that they can be understood A double line between 2 people indicates a functional relationship A single line with a break in the middle indicates dysfunction

Three parallel lines between 2 people denotes an overinvolved relationship where there is plenty of intrusion A solid line perpendicular to the relationship line symbolizes a rigid boundary where the rules are clear but non-negotiable

……..

A broken line perpendicular to the relationship line symbolizes a boundary that is clear but negotiable A dotted line perpendicular to the relationship line symbolizes a boundary that is diffuse or unclear A bracket encompassing several people signifies presence of a coalition or alliance between these people

An arrow pointing away from the system signifies escape from the system An open ended arrow with its open end embracing 2 individuals and the pointed end pointing to a 3rd signifies that the 3rd person is being triangulated by the conflict between the other two.

2. PRIMARY AND SECONDARY CARE

the Biopsychosocial Approach

48

4/1/19

BIO --PSYCHO—SOCIAL Medical   Management     Psychological   Emotional   Aspect  

Social     systems   -­‐ Family   -­‐ Community   -­‐ National   -­‐ Global  

BPS Model background ›  Shifting

of paradigms

›  Methodology ›  Hierarchy ›  Typology

of Natural Systems of illness

Paradigm shift the Old Paradigm ›  Age of Specialization - the Structure of Scientific Revolutions › 

Thomas Kuhn ›  Creation

of a New Paradigm [Reinvention of the old patient care model] ›  Unity

of the mind and body ›  Social contexts of illness

SHIFTING PARADIGMS

› BEFORE

1910

› FLEXNER

REPORT › Birth

of a new paradigm

The AUTHOR

Methodology › Scope ›  Physician’s

ability to diagnose disease

› Factors

that could contribute to the person’s illness and patienthood › “sickness

conditions” ›  “problems of living”

the

SYSTEMS theory person family community

› Systems

theory is a response to the

mechanistic world view and reductive methods of 19th century science ›  Reductive

methods dealt with problems by cutting them down to size, separating them from their surroundings and reducing them as far as possible to simple linear causal chains

A system is a dynamic order of parts and processes standing in mutual interactions with each other Von Bertallanfy, 1968

address patient’s health problem by incorporating all the significant relationships

Biosphere Society-Nation Culture-Subculture Community Family Two-Person

Personal Nervous System Organs Tissues Cells Organelles Molecules

Engel’s Hierarchy of Natural Systems

Atoms

Maglonzo, E. 2003. The Filipino Physician Today. UST, España, Manila:UST Publishing House

Subatomic

Existential Global Society/Nation Culture/Ethnic Community

SOCIAL

Family

Personal Body Systems Organs

ORGANISMIC

Conceptual Framework for Clinical Reasoning:

ANALYSIS of DATA & Tissues SYNTHESIS of Cells SOLUTION Organelles Molecules Atoms Subatomic

60

›  A person

is at the highest level of the organismic hierarchy and at the lowest level of the social hierarchy. › 

Ian McWhinney, Textbook of Family Medicine, 1997

4/1/19

Typology of Illness › Focus

of interaction –

person, the family dynamics and his illness › Categories

on psychosocial typology – onset, course, and outcome › Time phases of illness – crisis, chronic, terminal › Psychosocial determinants of health

Rolland’s psychosocial typology Acute illness (crisis phase)

• Family routines are suspended • High emotions • Initial coping or adaptation • Doctor’s role – facilitate healthy response, acceptance of diagnosis and recognize dangers (delayed or prolonged reaction)

Chronic illness (readjustment phase)

• Prolonged fear and anxiety • High incidence of illness in other family members • Over-indulgence towards the sick member resulting to overwork • Doctor’s role – encourage ventilation of feelings, give reassurance and reinforce care

Terminal illness (life-limiting phase)

• Death is inevitable • Devastating emotions – grief, mourning, shock, or overwhelming anxiety • Family’s reactions – members may be drawn close together or start to stay apart ending into family discord and breakdown • Physicians’ roles: • Assist patient and his family • Provide quality care

HEALTH

ONSET

ADJUSTMENT TO PERMANANCY OF OUTCOME

REACTION TO DIAGNOSIS FAMILY

EARLY ADJUSTMENT TO OUTCOME

SYSTEM

MAJOR THERAPEUTIC EFFORT

2. PRIMARY AND SECONDARY CARE [use of the Biopsychosocial Approach] ›  Effectiveness

in seeing undifferentiated patient

›  Recognize

the various modes of presentation

›  Adequate

knowledge of diseases of various

of illness

age groups

the various factors that impact on the health/illness of patients

›  Recognize

2. PRIMARY AND SECONDARY CARE [use of the Biopsychosocial Approach] continuing, comprehensive and personalized care to patients with

›  Provide

chronic conditions

› Coordinate the care of patients with

other subspecialties or agencies to achieve optimum health of the patient

5-star Physician EDUCATOR/ Counselor Every encounter _an opportunity for prevention

CLINICIAN/ Care Provider Patient centered Family focused care

MANAGER Coordinator of care and resources

the FAMILY PHYSICIAN “generalist”

RESEARCHER Evidence-based medicine user

ADVOCATE “population at risk”

ALMA ATA DECLARATION, 1978

NATURAL  HISTORY  OF  ANY  DISEASE  PROCESS  IN  MAN   Pre-­‐pathogenesis  period         Before  man  is  diseased     Interaction  of:     Disease     Human     agent   host         ENVIRONMENTAL  FACTORS   which  produce   DISEASE  STIMULUS  

Period  of  pathogenesis          

THE  COURSE  OF  DISEASE  IN  MAN  

DEATH  

 

Chronic  

CLINICAL HORIZON    

Early  pathogenesis  

State  

Discernible early disease

Advanced disease

Interaction  of  HOST   and  STIMULUS                                                                                                                                        recover      

Convalescence  

Disability  

preventive health behavior

the HEALTH BELIEF MODEL

Perceived

Susceptibility

to health problem or Perceived Seriousness

Perceived Threat of a health problem

Perceived Benefits of/Barriers to a preventiv e action

Likelihood of taking the preventiv e health action

NATURAL  HISTORY  of  any  DISEASE  PROCESS  in  HUMAN   Pre-­‐pathogenesis  period         Before  man  contracts   disease   interaction  of_     Disease     Human     agent   host         ENVIRONMENTAL  FACTORS   (disease  stimulus)  

PERIOD OF PATHOGENESIS        

THE  COURSE  OF  DISEASE  IN  MAN  

 

Chronic  

CLINICAL HORIZON    

Early  pathogenesis   Epidemiologic  Triad                        dynamics   RECOVERY

primary prevention

DEATH  

secondary prevention

Discernible Advanced early disease disease RECOVERY

 

RECOVERY

State   Convalescence  

RECOVERY

TERTIARY PREVENTION

Disability  

Key POINTS in the
 levels of prevention: 1. 

Primary Prevention and Predisease ›  › 

2. 

Secondary Prevention and Latent Disease ›  › 

3. 

Health Promotion Specific Protection Early diagnosis Prompt treatment

Tertiary Prevention and Symptomatic Disease ›  › 

Disability Limitation Rehabilitation

71 Monday, April 1, 19

Stage of Disease

Level of Prevention

Appropriate Response

Leavell’s Levels of Prevention

PREDISEASE

No known risk Primary prevention factors

Health Promotion – healthy changes in

Disease susceptibility

Primary prevention

Specific Protection – recommended

LATENT DISEASE

Secondary prevention

Screening (populations) Case Finding (individuals) Prompt treatment

Initial care

Tertiary prevention

Disability Limitation – medical and surgical

Subsequent care

Tertiary prevention

Rehabilitation – identify and teach methods

lifestyle, nutrition, and environment

nutritional supplements, immunizations, occupational and automoblie safety measures

SYMPTOMATIC DISEASE treatment to limit damage from the disease and institute primary prevention measure

to reduce physical and social disability

72

Based on the concept of prevention by LEAVELL, the key messages are: ›  All

of the activities of clinicians and other health professionals must have the goal of prevention. ›  What is to be prevented depends on the stage of health or disease in the individual receiving preventive care. ›  Primary prevention keeps the disease process from becoming established by eliminating the causes of disease or by increasing resistance to the disease. ›  Secondary prevention interrupts the disease process before it becomes symptomatic. ›  Tertiary prevention limits the physical and social consequences of symptomatic disease 73

..According to Dr RENE SAND

‘Health  can  not  be  simply  given  to  the   people;  it  demands  their  participation’  

74 01 April, 2019