1-concepts and principles of fm & phc-f-med07

7/31/2019 1-Concepts and Principles of FM & PHC-F-Med07

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Dr. JAWAHER AL-AHMADIMB. ABFM. SBFM. MSc.


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Objectives

To list and explain the different level of healthcareTo know developmental history of the specialty

To define family medicine and primary careTo list and explain the Principles of familymedicine

To understand the characteristics and role of family physicianTo know Innovations in family medicineTo know misconception regarding familymedicine


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Content

Developmental history of the specialtyFamily medicine and Primary care

Innovations and misconception in familymedicine


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Levels of health carePrimary heath care .Primary heath care centers

Secondary health careGeneral hospital

Tertiary health careUniversity & highly specialized hospital


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Terms of Reference

SciencesGeneral medicine

Primary carePrimary care medicine

Family medicine

PractitionersGeneral practitioners

Primary care practitionersFamily practitioners

Sites of practiceGeneral practice

PHCFamily practice

General and polyclinics


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Overview

Modern medicine had fragmented the healthcare delivery systemEmergence of major specialtiesFragmentation of the professionsTechnology rather than human orientedapproachRapid return of the generalist physician whowould give comprehensive, personalized carewas urged


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The trend toward specialization gained

momentum through the 1950s, and fewerphysicians entered general practice. In the early1960s, leaders in the field of general practicebegan advocating a seemingly paradoxical

solution to reverse the trend and correct thescarcity of general practitioners the creation ofstill another specialty.These physicians envisioned a specialty thatembodied the knowledge, skills, and ideals theyknew as primary care.


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In 1966, the concept of a new specialty inprimary care received official recognition in twoseparate reports published 1 month apart. Thefirst of these was the report of the Citizens'Commission on Medical Education of theAmerican Medical Association, also known asthe Millis Commission Report.The second report came from the Ad Hoc

Committee on Education for Family Practice ofthe Council of Medical Education of theAmerican Medical Association, also called theWillard Committee (1966)


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Three years later, in 1969, the AmericanBoard of Family Practice (ABFP) came into

being as the 20th medical specialty board.The name of the specialty board waschanged in 2004 to the American Board of

Family Medicine (ABFM)


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The Origins Of Family MedicineChanges in mortality & morbiditySuccessful control of infectious diseases

Increasing incidence & prevalence of chronic diseasesAccidentsBehavioral disordersNewly emerging and re-emerging diseases

Population growthIncreased life spanThe changing role of the hospital.Managed care and the age of integration.


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New Developments In The Behavioral SciencesNew insightsBetter understanding of human behaviorsand needs.Better understanding of the roles of family& society in the health care system


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Family Medicine

Family medicine is the medical specialty thatprovides continuing and comprehensive

health care for the individual and the family . Itis the specialty in breadth that integrates thebiologic, clinical, and behavioral sciences.The scope of family medicine encompassesall ages, both sexes, each organ system, andevery disease entity.


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Family Physician

The family physician is a physician who is educated andtrained in the discipline of family medicine. Familyphysicians possess unique attitudes, skills, andknowledge that qualify them to provide continuing andcomprehensive medical care, health maintenance, andpreventive services to each member of a familyregardless of sex, age, or type of problem (i.e., biologic,

behavioral, or social).These specialists, because of their background and

interactions with the family, are best qualified to serve aseach patient's advocate in all health-related matters,

including the appropriate use of consultants, healthservices and communit resources AAFP 1993 .
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WONCA definition of family doctor

The World Organization of Family Doctors (WorldOrganization of National Colleges, Academies, andAcademic Associations of General Practitioners andFamily Physicians [WONCA]) defines the family doctor inpart asthe physician who is primarily responsible for providing

comprehensive health care to every individual seeking

medical care, arranging for other health personnel to provide services when necessary. The family physician functions as a generalist who accepts everyone seeking care, whereas other health providers limit access to their

services on the basis of age, sex, or diagnosis ( WONCA,1991 )
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Primary Care / Family PracticePrimary care is that care provided by physiciansspecifically trained for and skilled incomprehensive first contact and continuing carefor ill persons or those with an undiagnosed sign,symptom, or health concern (theundifferentiated patient) not limited byproblem origin (biological, behavioral, or social),organ system, or gender.


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Primary care is a form of delivery of medical carethat encompasses the following functions:

It is highly personalized first-contact care, servingas a point-of-entry for the patient into the health caresystem;

It includes continuity by virtue of caring for patientsover a period of time, both in sickness and in health;It is comprehensive care, drawing from all thetraditional major disciplines for its functional content;


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It serves a coordinative function for all thehealth-care needs of the patient;

It assumes continuing responsibility forindividual patient follow-up and communityhealth problems; andIt is a highly personalized of care .


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WHO IS A PRIMARY CARE PHYSICIAN ?A primary care physician is a generalist

physician who provides definitive care to theundifferentiated patient at the point of firstcontact and takes continuing responsibility forproviding the patients care.

Primary care physicians devote the majority oftheir practice to providing primary care servicesto a defined population of patients.


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Primary care A care which provides integrated , accessible health care services by clinicians who are

accountable for addressing a large majority of personal health care needs, developing asustained partnership with patients, in thecontext of family and community .


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Why is this?Preventive services are more consistentlydelivered

Chronic diseases, such as asthma,cardiovascular disease, and diabetes, arebetter managed

Acute problems are diagnosed and treatedearlier


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Primary carePrimary care providers includeFamily physiciansGeneral internistsGeneral pediatriciansFamily nurse practitioners (and some adultcare and pediatric nurse practitioners) somephysician assistantsGynecologists


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Primary care ( Advantages )Physicians care is aimed at preventingadverse, costly events such as

hospitalizations and further morbidity, theyare well positioned to address the majornational health priorities


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Role of Primary Care In AddressingHealth Care Priorities

An extensive variety of common, rare, andundifferentiated problems are managed in primary care.Management included a diagnostic process where thepatient presents with new symptoms and leaves with anew or provisional diagnosis.Prevention is practiced broadly in primary care visits, andnot just during physicals .During 32% of illness visits, the family physician deliversat least one preventive service


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CASEMr. Ahmed is a 48-year-old gentleman wholives with his wife, Sara, and their 6-year-old

son, Ali.He has recurrent abdominal pain and achronic cough. He self-medicates with over-the-counter antacids and cough syrup.Sara, is a housewife , her most persistentcomplaint is chronic pain in her shoulders,neck, and upper back.Several months a o, when in the emer enc


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Their son, Ali, receives his immunizations atpolyclinic. He has asthma and is occasionally

brought to an urgent care clinic when hissymptoms get bad


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QuestionsWhat options exist to provide this family withthe care that is both affordable and in line

with principle of good primary care practice ?

What are those principles?

Would this family be better served by aprimary care based health system or a

specialty based care?


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Health system in KSA

Every country has todevelop a healthsystem capable of meeting the priorityhealth needs

Area of 2,240,000

Sg. Km.16 million. Densityof 6 persons/Sg.Km.


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45% Lives in largecities

Hajj & OmraClimate


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ESTABLISHMENT OF PHC

Till the year 1399 H,health services were

delivered in terms of Curative:HospitalDispensaries

Preventive:Health officesMCH Centres


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The World Health Assembly decided in 1977 that themain social target for Governments & WHO is:

HEALTH FOR ALL BY THE YEAR 2000

Alma Ata Declaration 1978

PRIMARY HEALTH CARE


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THE MEDICAL ECOSYSTEM

- Enlarging Circle of Influence

DOCTOR PATIENT

Disease DiagnosisHealth Promotion

Disease Prevention Therapy

Medical InsuranceManaged Care

Hospital

Laboratories

PharmaceuticalIndustry

Patients Family,Culture, Religion

Patients Work, Employer

Other Doctors

Paramedics

ClinicManagement

Public Health

MedicalResearch

MedicalStudents

CME,CPD

DoctorsEmployer

DoctorsFamily

DoctorsEmployee

PracticeManagement

MDO

Medical Council

The LAWGovernmentBodies

MedicalCharities

PatientOrganisation

AlternativeMedicine

Press, Media

National Community

International Community

Natural Disasters

PoliticalUpheaval, War


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Ministerial Decree No. 2571/1459/50 dated 17.8.1400(1980)

ESTABLISHMENT OF HEALTH CENTRES:Health officesMCH centresDispensaries

PHC CENTRES development was initiated in 1404
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DEFINATION OF PHC

Essential health careBased on practical, scientifically sound and socialacceptable methods & technology

Accessible to individuals & familiesIt is their first level of contactCost that the community & country can affordIt forms an integral part for both the countrys healthsystem & the overall social & economic development


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ELEMENTS OF PHC

PROMPOTIVE :Health EducationFood supply & proper nutrition

Maternal & Child care

PREVENTIVE:

ImmunizationPrevention & control of locally endemicdiseases

Adequate supply of safe water & basicsanitation


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ELEMENTS OF PHC

CURATIVE:Treatment of common diseases & injuriesProvision of essential drugs.

ADDITIONAL ELEMENTS:Dental care

Mental healthSchool healthHome health care


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PHC PRINCIPLLES

Equity in distribution :Services to all & more services to the needy

Appropriate Technology:That the people can use & afford.

Multisectoral approach:Municipalities, Ministry of agriculture,

Education


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PHC PRINCIPLLES

Community participation:- Social awareness & community self reliance.- The people has the right and duty to

participate in the process for the improvementand maintenance of health.Support from higher levels of care :

- Hospitals has to share the social goal of making essential health services.

- Referral


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Principles of Family Medicine

Continuity of careComprehensiveness

Coordination of careCommunity orientationCommunication skill


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Principles of Family Medicine

Cost effectivenessPrevention focus

Evidence-based practiceBiopsychosocial, life-cycle perspectiveFamily-centeredness


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Continuity Of CareThe average family medicine patient has seen the samephysician 20 times over the previous 5 yearsThis provision of care by the same provider over time iscalled continuity of care Continuity of care facilitates implementation and trackingof screening tests and other services that should berepeated periodicallyContinuity visits also provide opportunities to reinforce amessage with repetition


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Comprehensiveness

A Family Physician manages between 85% to90% of the patient who present in the primarycare.Provision of a wide variety of services coveringthe majority of patient needs is termed ascomprehensiveness of care The family physician must be comprehensive

trained to acquire all the medical skills necessaryto care for the majority of patient problemsincluding, each specialty according to itsprevalence.


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Comprehensive CarePromotivePreventive

CurativeRehabilitive


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Coordination of careDuring 10% of office visits, a referral is made to amedical specialist, mental health provider, physicaltherapist, social worker, or other health professionalBeing aware of the variety of services available makingappropriate request for consultations or referralsCollecting and interpreting results of the studies andspecialist visitsAdvising when additional care is neededGate keeping models/coordination of care


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The family physician facilitates the patientsaccess to the health care system ,

interprets the activities of this system to him, explaining the nature of the illness ,implications of treatment, and the effect ofboth upon the patients way of life.Millis Commission Report.


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Case

Mr. F, a 60-year-old patient in your practice,presents to the emergency department with abowel obstruction.The ensuing work-up reveals colon cancer as

the cause, and he undergoes bowel resectionwith multiple positive nodes but no distantmetastases identified.

You refer him to Dr. G, a local oncologist, whorecommends aggressive therapyWhat should family physician do with thispatient?


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Community Orientation

Good medical practice requires this

orientation , because what happens inhomes, schools, worksites, healthdepartments, and elsewhere in thecommunity can have profound effects onindividual health and quality of life.


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Prevention focusPreventive care is the most common reason patient's visita family physician's officePremarital care

Prenatal careWell baby checkupsWell child examinationsAdolescent care

Routine adult physicalsElderly carePre-employment physicalsVisits as preparation for international travel


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Prevention focusMeasure to reduce disease riskImmunizations

Measure to prevent morbidity in patient whohave established diseasePrevention of secondary disability in people

with disease related morbidity


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Evidence-Based MedicineAn evidence-based approach means that theclinician has made the effort to identify the

strongest, most valid studies, is able tochange his or her mind about a test ortreatment when the evidence supports achange in practice.


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Evidence-Based MedicineAn evidence-based approach means that theclinician has made the effort to identify the

strongest, most valid studies, is able tochange his or her mind about a test ortreatment when the evidence supports achange in practice.


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Quality drivenScientific soundness.Essential skills.Appropriate technology.Clinical guidelines.Certification and re-certification.CME & CPD.Audit and peer review.Accreditation and re-accreditation.


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Biopsychosocial, Life-Cycle PerspectiveEffective primary care physicians viewpatients from a broad perspective, taking intoaccount physiology, physical illness,emotional health, and the social,occupational, and environmental contextwithin which the person lives.

Biopsychosocial approach is importantbecause health and illness behavior arestrongly colored by the personality andenvironment of the patient.


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Biopsychosocial, Life-Cycle Perspective

For example, whether or not a patient willactually take a prescribed medicine willdepend on many factors

Medication's costThe experience of the person and others he

or she knows with similar medical treatmentInteraction between side effects and theperson's needs (e.g, Alertness or sexualpotency)


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Family OrientationQuality primary care must take into accountthe family contextBy family we mean the entire range ofrelationships whether or not by blood ormarriage that can comprise a patient's closesocial networkMost health behaviors and illness episodesinvolve some connection with the patient'ssocial support network


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Family OrientationSeventy percent of patients seen in thesefamily physician visits have another family

member seeing the same physician.In 18% of visits, care is provided to anotherfamily member in addition to the identifiedpatient.


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Family OrientationThe man who develops a chronic illness thatwill require him to perhaps eat differently or

alter his recreational patterns.As more sophisticated electronic information

systems and further maturation of appliedgenetics, it is likely that the importance of afamily orientation will increase

Cost Effecti e C re


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Cost Effective Care

Knowing their patients well family physician

are capable of:Assessing the nature of their patientshealth problem more rapidly andaccurately.

Using time as an ally in diagnosing lessurgent problems.Ensuring the most logical and economicalmanagement.

Controlling magnification of simpleproblem.Ordering fewer test.


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AccessibilityServices must be available when needed

and should be within geographicproximity


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PERSONALIZED CARE

It is much more important to know what sort of patienthas a disease than what sort of disease a patient has.Family practice emphasizes consideration of theindividual patient in the full context of his or her life,rather than the episodic care of a presenting complaint.The family physician serves as the patients advocate,explaining the causes and implications of illness to thepatients and their families, and serves as an advisor andconfidant to the family- both individually and collectively


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Home CareHome visits

Outreach activities


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A strong sense of responsibility for the total,ongoing care of the individual and the familyduring health, illness, and rehabilitation

Compassion and empathy, with a sincereinterest in the patient and the family

A curious and constantly inquisitive attitude.


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Enthusiasm for the undifferentiated medical

problem and its resolution

An interest in the broad spectrum of clinical

medicine.

The ability of deal comfortably with multiple

problems occurring simultaneously in one


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A desire for frequent and varied intellectualand technical challenges

The ability to support children during growthand development and during theiradjustment to family and society

The ability to assist patients in coping witheveryday problems and in maintainingstability in the family and community


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The capacity to act as coordinator of all

health resources needed in the care of apatient

A continuing enthusiasm for learning andfor the satisfaction that comes fromremaining current through continuingmedical education

The ability to maintain composure in timesof stress and to respond quickly with logic,effectiveness, and compassion.


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A desire to identify problems at the earliestpossible stage (or to prevent diseaseentirely)

A strong wish to maintain maximum patientsatisfaction, recognizing the need forcontinuing patient rapport


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The skills necessary to manage chronicillness and to ensure maximal rehabilitationfollowing acute illness

An appreciation for the complex mix ofphysical, emotional, and social elements inholistic and personalized patient care


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A feeling of personal satisfaction derived

from intimate relationships with patients thatnaturally develop over long periods ofcontinuous care, as opposed to the short-term pleasures gained from treatingepisodic illnesses

A skill for and commitment to educatingpatients and families about diseaseprocesses and the principles of good health


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A truly comprehensive primary care (family)physician adequately

Manages acute infections.Biopsies skin and other lesions.Repairs lacerations.

Treats musculoskeletal sprains and minorfractures.Removes foreign bodies.Treats vaginitis and provides obstetric care.Care for the newborn infant.Gives supportive psychotherapy.Supervises or performs diagnostic procedures.


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Management of an illness involvesmuch more than a diagnosis and an outline

for treatment . It requires :Awareness of the factors aiding orhindering recovery from illness.Consideration of religious beliefs; social,economic, or cultural problems; personalexpectations; and heredity.The outstanding clinician recognizes the

effects that spiritual, intellectual, emotional,social, and economic factors have on apatients illness.


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Illness Behavior

Factors Affecting Illness Behavior

Gender

AgeRaceLearned behavior

Accessibility to healthservices

Symptom presentation

Lay beliefsSocial ClassPrevious experience

Trigger factorsLocus of control


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The health belief model

HealthmotivationPerceived vulnerability

PerceivedseriousnessPerceived costs

and benefits


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The family physicians ability to confront relatively

large numbers of unselected patients withundifferentiated conditions and carry on atherapeutic relationship over time is a uniqueprimary care skill.

The early identification of disease while it is in itsundifferentiated stage requires specific trainingand is not a skill that can automatically beassumed by someone whose training has beenmostly in hospital intensive care units.

Communication Skills


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Who isthe

patient ?!

Communication Skills


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Interpersonal Skills

One of the foremost skills of the familyphysician is the ability to effectively utilize the

knowledge of interpersonal relations in themanagement of patients. This powerfulelement of clinical medicine is perhaps thespecialtys most useful tool.


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Develop compassion and courtesy.Establish rapport.Communicate effectively.Gather information rapidly and to organize itlogically.Identify all significant patient problems andmanage them appropriately.Listen , observe patients and detect nonverbalclues.

Motivate people.

To relate well to patients, a physician must :


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Case DiscussionThe case of the Mr.Ahmed familyillustrates how psychosocial,environmental, and biomedical factorsinteract, and how understanding all of them is essential to making an accuratediagnosis and implementing effective

treatment.Given that history, and his chronic cough,inquiry about his smoking history wouldbe important.


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Saras symptoms are highly suggestive offibromyalgia, a common musculoskeletaldisease that invariably requires psychosocial,biomedical, and environmental approaches toeffectively treat.Her history is highly suggestive of type 2

diabetes, the diagnosis and treatment ofwhich are likely to have been delayed .


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Ali receives adequate preventive care butdoes not receive ongoing primary care for his

asthma, and since access to continuity of care is associated with better asthma control,lack of access to comprehensive primary careservices is likely to be contributing to hisasthma morbidity.


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Primary care versus subspecialty basedcare.

The supply of primary care physicians wassignificantly associated with lower all-cause

mortality, whereas a greater supply ofsubspecialty physicians was associated withhigher mortality. In contrast, sub specialist-focused care tends

to lead to higher costs and poorer healthoutcomes.


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Innovations in primary careIncreased us of the Nurse practioners,Physicians Assistants, and Office Medical

AssistantsElectronic Health RecordsElectronic communication with patient

Home care practices


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Innovations in primary careOpen Access schedulingOutcome based management of chronic

diseasesGroup visits


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Misconceptions About The Roles Of Generalists& Specialists

The generalist has to cover the whole field of medical knowledge.

In any field of medicine the specialist alwaysknows more than the generalist.By specializing one can eliminate uncertainty.


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Misconceptions About The Roles Of Generalists &Specialists (contd)

Only by specialization one can attain depthof knowledge.Error in medicine is usually caused by lack of information.


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Final Message & Conclusions

A lot of practice is needed to be able tobecome a family physcian


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