Transcript МИСИЯТА

10
YEARS
GENERAL MEDICINE
MEDICAL UNIVERSITY
PLEVEN, BULGARIA
FACULTY OF “PUBLIC HEALTH”
Realizing Primary Health Care
The symbol of General Practitioners /Family Doctors in Bulgaria
Rev. “General medicine” , Sofia,1999, tom I, Nr 1, page 2.
The mission...
QUALITY OF LIFE
and
GENERAL/FAMILY MEDICINE
“ AN IDEA WHOSE TIME HAS COME ! “
M. Goranov, MD, PhD, Chairman of BATGP
GP’s FOR
QUALITY
OF LIFE !
European
“The profound changes now occurring
in medicine
Health Care
Reform
can only be
fully understood
if they are viewed from the perspective of history.
There is nothing new about change:
medicine has been changing constantly
since its beginnings.
…Only the pace is different.”
(Ian McWhinney, “A Textbook of Family Medicine”, New York-Oxford, 1997).
Back to the future!
mission…
/lat. “missio” = action, burden, load/
1.
WARRANTY.
WARRANT OF ATTORNEY FOR SOMEONE TO REALIZE SOMETHING.
2.
CONSECUTION OF INSTRUCTIONS FOR LOYAL, DEVOTED AND
TRUSTWORTHY OR PRESCRIPTIONS FOR CONVERSION OF SINNERS.
3.
LEGATION.
4.
MISSIONARY’S RULES.
(”Petit Larousse”, Paris, 1966)
THE MISSION… of medicine
General/Family medicine today
THE MISSION OF HUMAN MEDICINE TODAY:
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TO IMPROVE THE QUALITY OF ACTIVE LONGEVITY;
TO BUILD UP and firmly consolidate strengthening
HEALTHY LIFE STYLE, to preserve and to reestablish it;
TO INVESTIGATE AND MASTER ILLNESS and DISEASE;
TO PROTECT, TO CARE and TO CURE PEOPLE.
THE MISSION OF GENERAL/FAMILY MEDICINE TODAY:
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BASED ON “HOLISTIC” APPROACH /bio-psycho-social/… and
working in a team with other medical and non-medical services,
to competently offer MULTIDISCIPLINARY HEALTH CARE to
persons, families and communities,
SOLVING NOT ONLY MEDICAL but HEALTH PROBLEMS too !
THE MISSION…
GENERAL or FAMILY MEDICINE…
That was what made family practice unique
among others clinical disciplines, this is an idea of
“THE FAMILY AS ONE PATIENT”
Epistemological, family medicine is the name of body
of special knowledge and particular approaches that
includes the family, but much else besides…
Since the moment in which other clinical disciplines, captivated
by laboratories, high technologies and analytical methods, deserted
permanent, closely integrated and daily exhaustive health problems
of the individual, of the family and of the community,
ONLY FAMILY MEDICINE IS THE ACADEMIC DISCIPLINE,
which is in its rights to closely accompany and particularly attend upon them.
...And to resolve them in its proper HOLISTIC APPROACH.
THE MISSION…
PHC – General/Family medicine…
• APPROPRIATED TO OUT-HOSPITAL HEALTH NEEDS,
INCREASING LIFE EXPECTANCY AND QUALITY OF LIFE,
GENERAL MEDICINE OF TODAY
REPREZENTS A SEPARATE CLINICAL DISCIPLINE,
EQUAL TO OTHER HOSPITAL DISCIPLINES.
• AS A NEW SCIENCE, THIS DISCIPLINE EXPLORES A
NON-TRADITIONAL SPECIFIC SETTINGS OF :
- NEW KNOWLEDGE,
- NEW SKILLS and
- NEW ATTITUDES.
• FAMILY MEDICINE
A HIGHER EVOLUTIVE LEVEL,
BASED ON THE BEST OF GENERAL MEDICINE.
IS A BRANCH,
THE MISSION…
General/Family medicine - Specifics…
AS A MULTIDISCIPLINARY AND POLIVALENT
CLINICAL SPECIALITY OF PRIMARY HEALTH CARE,
I. E. A SPECIALITY OF OUT- HOSPITAL HEALTH CARE,
AND
SOLVING
SOMATIC
SOME
AND PSYCHOLOGICAL MEDICAL PROBLEMS,
GENERAL/FAMILY MEDICINE SHARES ITS TERITORY
WITH OTHER CLINICAL DISCIPLINES,
WITH OTHER
HOSPITAL SPECIALITIES.
BUT !
IN PHC,
GENERAL/FAMILY MEDICINE USES HOSPITAL
AND YET
CUMULATIVE KNOWLEDGE AND SKILLS IN APPROPRIATE,
UNIQUE AND
UNREPEATABLE MANNER,
REFINING… ENRICHING… HUMANIZING THEM WITH NEW APPROACHES.
THE MISSION…
GM/FM – Holistic approach…
WHY appropriate?
WHY unique?
WHY unrepeatable?
WHY ?...
WHY ?...
WHY ?...
THE MISSION…
GM/FM - Primary Health Care…
…BECAUSE
there ARE DIFFERENT :
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Patient’s health needs and expectations in out-hospital medicine;
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Political, economical and social order for Primary Health Care;
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Manners of doctor-patient communication - hospital and out-hospital;
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Delimitation of some terms as: “disease”, “illness”, “anticipatory care”;
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Contrivances for definition of: “health status”
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Meanings of, and approaches to: “symptom”, “health problem”, “diagnosis”;
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Patient’s unrestricted choice - of doctor, treatment, behavior or dependence;
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Patient’s autonomy as personality - as a social and not only biological entity;
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Practical use of relationships - problems and pitfalls; bereavement counseling.
HEALTH PROMOTION
AND
or
“un-organized illness”;
DISEASE PREVENTION, REGARDED AS PART OF A CONTINUUM,
HAVE THE COLLECTIVE AIMS OF WHICH ARE: 1. TO IMPROVE QUALITY OF LIFE.
2. TO REDUCE BURDEN OF PREMATURE DISABILITY.
3. TO INCREASE LIFE EXPECTANCY.
THE MISSION…
GENERAL/FAMILY DOCTOR - DEFINITION :
The general practitioner or family physician is a licensed specialist who is primarily
responsible for providing personal, continuing and comprehensive care for
everyone seeking health care: for the individual in the context of family and for
the family in the context of the community - irrespective of race, religion, culture
or social class; irrespective of age, sex and/or diagnosis.
He is a synthesis of these functions, which is uniquely… He is clinically competent to
provide the greater part of care after taking into account cultural, socioeconomic
and psychological background… He deserves his patient home, in office,
sometimes in hospital… ether directly, either through the services of others… His
first aim is to make early diagnosis.
He includes and integrates in his work physical /biological/, psychological /mental/
and social factors in his consideration about health and illness.
He makes the initial decision about every health problem /differentiated or not/.
The General Practice is a continuing
fluent manifestation of classical practice in medicine,
deeply rooted in the history of humanity
and actually irrevocably linked with the family.
/Definition of American Academy of Family Doctors/
THE MISSION…
GP/FD and Health care - ALGORITHM:
KEY POZITIONS:
Gate-kipper - to specialist and/or hospital;
Bridge-builder - with other medical services;
Team-worker and major coordinator in PHC.
КEY FUNCTIONS:
First clinical decision making /problem solving/;
Engaged with patient’s problems to the end;
Realizing health promotion, prevention, education.
КEY SKILLS AND ATTITUDES:
Personality-oriented /bio-psycho-social approach/;
Family-focused /solving all problems in context/;
Community-relevant /beyond individual problems/.
КEY ABILITIES:
Care-manager /for allocation of scarce resources/;
Fund-holder /……………………………../;
Advocacy role /working with other authorities/.
What is needed in PHC is
knowledge of initial and
characteristic symptoms
of suffering or/and illness,
so that GP’s are able to
estimate the health status,
the gravity of situation or
disease, the alarm signals
of the latent distress,
even in cases
where no diagnosis
can be made…
THE MISSION...
GM/FM – New knowledge and skills for…
IN ORDER TO REALLY IMPRUVE QUALITY OF LIFE, GP/FDs NEED
WIDE GENERAL CULTURE
AND ALSO SPECIFIC UNDERSTANDING IN:
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Cultural anthropology /ethnos, traditions, religions, education…/;
Sociology /occupation, home, environment, customs, hobbies…/;
Psychology /insight, empathy, spiritual influence, emanation…/;
Behavioral sciences /motivations, reactions, causality of illnesses…/;
Family dynamics /aspect, function, phase, cycle, assessment of family…/;
Interpersonal skills /compassion, charisma, communication…/;
Еthics, aesthetics... value system… etc.
Patients and doctors are actors in a play
written by history, directed by culture, produced by politics.
/Per Fugelli, 1995/
МИСИЯТА...
GM/FM – The “winds of change”…
“The man who translates the hieroglyphics of the science into the plain
language of healing, certainly is the most useful.” Sir William Osler
Educating
the general medical practitioner
of the 21st century:
• Education for Competence;
• Education for Confidence;
• Education for Co-operation.
(The European Society of General Practice/Family Medicine – RCGP)
…because:
“WE CAN SEE ONLY WHAT WE KNOW
AND FOR WHAT WE HAVE BEEN TRAINED AND EQUIPED”
THE MISSION...
GPs/FDs – for QoL…
“There is no man in the world who knows all about medicine.
We have to learn to discover that our patients, their illnesses
and its meanings are much more than biological, pathological
and pharmaceutical facts.
We have to learn how to understand the patient as a part
and in unity of his/her family against his social background…
To analyze the ways in which these two factors influence
his/her Quality of Life.
Only then we will be able to use in full value our medical
knowledge and skills…”
Carl Whitehouse, 1998
Emeritus Professor, Doctor Honoris Causa of MU-Pleven.
THE MISSION...
GM/FM – The confidentiality…
The confidence of the physician
“If you do not believe in Yourself,
how can you expect
other people to do so?
“If you have not an abiding faith
in the profession,
you cannot be happy in it.
“Learn to see, learn to hear, learn
to feel, learn to smell, and know
that by practice alone you can
become an expert.“
Sir William Osler
“It is much more important to know what sort of patient
has a disease than what sort of disease a patient has.”
Sir William Osler
THE MISSION...
GM/FM – Autonomy and/or paternalism… for QoL
IN PHC, SUCCESSFUL MANAGEMENT OF HEALTH PROBLEMS REQUIRES
a negotiated plan, achieving a doctor-patient consensus
in which the patient has ownership and understanding.
Negotiation usually involves pragmatic compromise
OVER A THEORETICAL ACADEMIC, CLINICAL IDEALS AND DOGMAS
IN FAVOUR OF WHAT IS POSSIBLE, REAL, FEASIBLE AND USEFUL
in the patient’s social, family and personal context
/emotional – psychological – intellectual - volitional/.
AMONG GENERIC ISSUES OF ETHICAL DILEMMAS
POSED BY
AN AGING SOCIETY AND FACED BY PROFESSIONALS,
ARE:
• RESPECT /autonomy, self-determination, informed consent, paternalism?/;
• BENEFICENCE /assessing risk and benefits/;
• AND JUSTICE /just ways to distribute burdens and benefits/,
TAKING INTO CONSIDERATION:
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THE USE OF CHRONOLOGICAL AGE AS A CRITERION IN THE ALLOCATION OF SCARCE RESOURCES;
THE ROLES OF FAMILIES, PATIENTS, AND MEDICAL PERSONENELS IN DECISIONS TO LIFE-TREATEMENT;
LIMITS ON PATIENT/CLIENT AUTONOMY IN DECISION MAKING;
RELATIONSHIPS AMONG HEALTH-CARE PERSONNEL AND SOCIAL SERVICE PROVIDERS;
THE USE OF OLDER SUBJECTS IN BIOMEDICAL, BEHAVIOURAL, AND SOCIAL RESEARCH. /University of Vermont/
THE MISSION...
GM/FM - Negotiating with the patient…
NEGOTIATION IN GENERAL PRACTICE IS A COMPROMISE
BUT THE OTHER NAME OF THIS COMPROMISE IS “FINDING” :
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FINDING
THE DECISION APPROPRIATED TO THE PATIENT –
IN HIS/HER SOCIAL, FAMILY AND PERSONAL CONTEXT;
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FINDING
THE SPECIFIC AND SHARED STRATEGY OF ACTION,
AND NOT NECESSARILY HOSPITAL, BIO-MEDICAL STEREOTYPS;
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FINDING THE “PROBLEM - ORIENTED” CONSULTATION,
AND NOT ONLY PRACTICING “DIAGNOSTIC-ORIENTED” MEDICINE !
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FINDING THE “PATIENT - CENTERED” MEDICINE
AND NOT ONLY “DOCTOR - CENTERED“ … !
AND AT LAST ...
• FINDING… THE MEDICINE OF TRUE THINGS
THE MISSION…
GM/FM... “medicine of true things” …
The Doctor (1891) By Sir Luke Fildes 1843-1927
The GP/FD must be an advocate of the human right to be imperfect
THE MISSION...
GM/FM – Cultural and spiritual aspects…
Practicing doctors must be able to think about and freely to discuss
not only clinical… but also cultural aspects… as well as those questions which
are related to religion and religious, ethical and moral implications in
health care (e.g. food of Muslims or Jews, blood transfusion and Jehovah’ followers, etc.)
because:
SUFFERING KNOWS NO FRONTIER…
PEOPLE SUFFER INDIVISIBLE WITH THEIR WHOLE SELVES: PHYSICAL, MENTAL and SPIRITUAL.
ONE OF THE MOST COMMON ERRORS WE MAKE AS PHYSICIANS IS TO TREAT PAIN BUT IGNORE
OTHER DIMENSIONS OF SUFFERING: PHYSICAL ILLNESS IS ASSOCIATED WITH SPIRITUAL
SUFFERING; SPIRITUAL SUFFERING MAY BE MANIFESTED AS PHYSICAL OR MENTAL ILLNESS…
P R I M E (Partnership in International Medical Education) is an organization, where in conformity
with the Burrswood culture of healing, physicians and of Jesus ministry focused on spiritual
awareness in secular professional environments, exploring the interface between mind and spirit
in patient-centered holistic approach, realizing the real whole-person medicine. www.prime-international.org.uk
The greatest sin to our human brothers is not hating them
but being indifferent to them. This is the real substance of inhumanity.
/Bernard Shaw/
THE MISSION...
GM/FM – Evidence based medicine in PHC…
“Unitas, Libertas, Caritas”
(Uytenbogaert, anti-dogmatic theologian, ХVІІ-th century)
Unitas... where certainty is attained by numerical data;
Libertas... where doubt prevails and figures cannot decide;
Caritas... means respect and appreciation in patient care…
… and because:
“The overestimation of what medical science is capable of, has created
a dangerous myth which, as our experience reveals, is under a taboo”.
(R. A. deMelker, University of Utrecht, 1998)
“Some of what doctors do - collectively and individually - has no rational
basis”.
(An introduction to medical audit in GP, University of Liverpool, 1996)
“The revolution in medical science is still not realized but obligatory
crisis preceding it, is fully established.” (Dr G. Achterberg, ”Schweizerische Arztezeitung”, 1998)
“The application of scientifically based guidelines
is no medicine of the cookery book kind, with ready-made answers for practice,
but requires integration of scientific knowledge with clinical experience” /R. A. Melker/
THE MISSION...
GP/FD - The art of talking with the people…
Pasteur
Vesalius
Mendel
“Our modern doctrine is a contrivance of the word-catchers;
the art of talking rather than the art of healing!”
(Thomas Sydenham, THE WORKS, vol. I)
МИСИЯТА...
GENERAL PRACTICE - Position in medicine…
The SPECIAL AND UNIQUE POSITION OF GENERAL PRACTICE
“BETWEEN THE IVORY TOWER OF GREAT MEDICINE AND
DAILY LIFE NEEDS AND DIFFICULTIES OF GRASS-ROOTS” is:
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RELATIVELY INTELLIGIBLE PHILOSOPHY;
NEW STRATEGY OF CONSULTATION;
NEW SCIENTIFIC MODEL OF THE DOCTOR’S ROLE;
NEW PARADIGM OF HEALTH CARE;
MISSION REALLY HUMANE AND INTELLIGENT,
WHICH HAS NEVER TOUCHED TRADITIONAL MEDICAL EDUCATION YET;
WITH A GREAT “DECLARATION OF INDEPENDENCE”, CLAIMING FOR GPs:
POLITICO - ECONOMICAL INDEPENDENCE :
that means a liberal profession, a conditio sine qua non for personal doctoring;
MEDICO - SCIENTIFIC INDEPENDENCE ;
that means a cool distance to the biomedical establishment,
necessary to refine The Real Thing, which is not Coca-Cola, but a
GENERAL PRACTICE AS A SPECIALTY WITH ITS OWN SPECIFIC WEIGHT,
ITS OWN CORE CONTENT, ITS OWN PECULIAR SKILLS, ITS OWN PROUD IDENTITY.
R.A.deMelker
IF… YOU WANT TO BE A G P
(After Rudyard Kipling)
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IF A FELLOW - COUNTRYMAN
WOULD CURE AND CARE FOR MEN, YET
NEVER FORGET: "THE SICK ONE IS A PERSONALITY“;
IF THE FIRST APPEAL FOR HELP SCATTERED AS A PUZZLE
IN CONFIDENCE, TRUST AND HOPE WITH DEVOTION IS ADDRESSED TO ONE'S OWN DOCTOR;
IF THIS DOCTOR IS ABLE TO UNDERSTAND
THE PAIN OF BODY AND SOUL,
AND FIRST WILL GRASP THE PROBLEM, HERE AND NOW;
IF HE SHOULD DECIDE WHY AND HOW, SOMETIMES
THE SUFFERER WITH ANOTHER KIN-SOUL TO SHELTER YET NEVER LEAVING HIM WHILE HE IS ALIVE…
IF BY THE SAME ZEAL, WITH THE SAME SKILLS,
AT THE SAME WARM BREATH MOTHER, FATHER AND THE WHOLE TRIBE WILL COMFORT;
IF - BY CHANGING THEIR TINY WORLD GENTLY WILL PUT GUILT AND FEAR ASIDE ;
IF HE ALWAYS KEEPS CALM AND CONCERNED ,
AND TURNS UP - THROUGH STORM OR IN THE HEAT,
AWAKE OR ASLEEP - AT HOME… IN THE OFFICE…
IF THIS DOCTOR CAN APPEAR
TO BE NOT ONLY ALMIGHTY BUT
A BOSOM FRIEND TODAY, A PROPHET TOMORROW;
IF HE SHOULD SPARE YOUR WOE
AND SAVE YOUR COUNTRY'S RICHES
WITHOUT NEGLECTING HIS MATRIX ,
HIS OWN SPIRITUAL ESSENCE,
THEN THIS DOCTOR, MY SON,
IS MY CHERISHED, MY BULGARIAN GP .
HELPING
EACH PATIENT
REACH THE
HIGHEST
QUALITY OF LIFE
AND HEALTH !
By MITKO GORANOV, BULGARIA
Published in ”THE KIPLING JOURNAL”, June 2004, p. 50, LONDON, UK
10
YEARS
GENERAL MEDICINE
MEDICAL UNIVERSITY
PLEVEN, BULGARIA
FACULTY OF “PUBLIC HEALTH”