Transcript THE ORIGINS OF FAMILY MEDICINE

THE ORIGINS OF FAMILY
MEDICINE
DEPT. OF PUBLIC HEALTH & PREVENTIVE
MEDICINE
FACULTY OF MEDICINE-PADJADJARAN UNIVERSITY
2013
SPECIFIC LEARNING OBJECTIVES
• Understand family medicine as a discipline (C1)
• Recognize the changes in paradigm in medicine (C1)
• Understand the growth and background of family
medicine (C1)
• Describe the definition and scope of family medicine
(C2)
• Understand the place of Family Medicine and
integrating Family Medicine’s efforts in Health Care
(C1)
DEFINITION OF PUBLIC HEALTH
The science and the art of:
(1) preventing disease,
(2) prolonging life, and
(3) promoting physical health and efficiency through organized
community efforts for:
(a) the sanitation of the environment,
(b) the control of community infections,
(c) the education of the individual in principles of
personal hygiene,
(d) the organization of medical and nursing service for
the early diagnosis and preventive treatment of disease,
(e) the development of the social machinery which will ensure
to every individual in the community a standard of living adequate
for the maintenance of health so organizing these benefits as to
enable every citizen to realize his birthright of health and longevity
(Winslow, 1920)
PREVENTIVE MEDICINE:
a Specialized field of medical practice composed of
distinct disciplines which utilize skills focusing on the
health of defined populations in order to promote and
maintain health and well-being and prevent disease,
disability, and premature death (Last, 1987)
SOCIAL MEDICINE :
A term used to emphasize the importance of man’s
environment to his health. In this sense, environment
includes the human society in which man lives and the
multitude of complex interpersonal relationships that so
profoundly affect his health
(Leavell & Clark, 1958)
COMMUNITY MEDICINE
that branch of medical science which is concerned with the
health needs and interventions of population groups of
known size and composition. That is, it is concerned
with health of what is commonly known as defined
population groups
(Lathem, 1979)
DEFINITION OF FAMILY MEDICINE
Family Medicine (FM) is the medical specialty
that provides continuing and comprehensive
health care for the individual and the family. It is
the specialty in breadth that integrates the
biologic, clinical, and behavioral sciences. The
scope of FM encompasses all ages, both sexes,
each organ system and every disease entity
(American Academy of Family Physicians/AAFP, 1993)
FAMILY MEDICINE AS A DISCIPLINE
(LEE GAN, AZWAR AND WONODIREKSO, 2004)
• The other names: general practice or primary care
medicine
• Family medicine is a discipline concerned with the
provision of personal, primary, comprehensive and
continuing health care of the individual in relation to
his family, community and his environment
• The term is preferred to emphasize the family as a
sociological unit providing support to the individual as
well as to reiterate the importance of the family in the
cause and effect of health and disease in the
individual.
PREVENTIVE
MEDICINE
SOCIAL
MEDICINE
FAMILY/PRIMARY
CARE MEDICINE
COMMUNITY
MEDICINE
SCIENTIFIC APPROACHES IN PUBLIC HEALTH
Epidemiology, Biostatistics ,Biological & physical sciences ,Social sciences,
Demographic science, Surveillance, Intervention and Evaluation
FAMILY DOCTOR/ PHYSICIAN
(WONCA, 1991)
The physician who is primarily responsible for
providing comprehensive health care to every
individual seeking medical care, and arranging for
other health personnel to provide services when
necessary.
The FP functions as a generalist who accepts
everyone seeking care whereas other health
providers limit access to their services on the basis
of age, sex, and/ or diagnosis.
FAMILY DOCTOR
(LEE GAN, AZWAR AND WONODIREKSO, 2004)
• is a qualified medical practitioner who provides personal, primary,
comprehensive and continuing health care of the individual in
relation to his family, community and his environment.
• he may attend to his patients in his clinic, in their homes or
sometimes in the hospital.
• in treating his patients, must take into consideration the whole
person, their psyche as well as their body systems and must not
treat just the signs and symptoms.
• in providing comprehensive and continuing care , he will need to
interact with his medical colleagues.
• in promoting health, he will not only treat therapeutically but also
educate and counsel his patients
PRIMARY CARE (AAFP, 1993)
Primary Care is that care provided by physicians specifically trained
for and skilled in comprehensive first contact and continuing care
for ill persons or those with undiagnosed sign, symptom, or health
concern not limited by problem origin (biologic, behavioral or
social), organ system or gender.
Primary Care includes, in addition to diagnosis and treatment of
acute and chronic illnesses, health promotion, disease prevention,
health maintenance, counseling and patient education, in a
variety of health care settings such as office, inpatient, critical care,
long term care, home care and day care.
Primary Care is performed and managed by a personal physicians,
using health professionals for consultation or referral as appropriate.
PRIMARY CARE
( AMERICAN BOARD OF FAMILY MEDICINE,
2004)
PC is a form of delivery of medical care that encompasses
the following functions:
1. It’s first-contact care, serving as a point of entry for the
patient into health care system
2. It includes continuity by virtue of caring for patients
over a period of time
in sickness and in health
3. It’s comprehensive care
4. It serves a coordinative function for all the health care
needs of the patient.
5. It assumes continuing responsibility for individual
patient follow-up and community health problem.
6. It is a highly personalized type of care
FAMILY MEDICINE
• HOW DID FAMILY MEDICINE BEGIN ?
• WHAT ARE THE REASON WHY FAMILY
MEDICINE HAS INCREASED ?
HOW DID FAMILY MEDICINE BEGIN ?
2. NEW
DISCIPLINE
1. PARADIGM CHANGES IN
MEDICINE
Old paradigm
FAMILY
MEDICINE
3. HAS EVOLVED
FROM G.P
new paradigm
1. WHAT IS THE OLD PARADIGM IN MEDICINE ?

IS ALSO KNOWN AS THE BIOMEDICAL MODEL

A DISEASE CAN BE VIEWED INDEPENDENTLY FROM THE
PERSON WHO IS SUFFERING FROM IT AND FROM HIS
SOCIAL CONTEXT

MENTAL AND PHYSICAL DISEASE CAN BE CONSIDERED
SEPARATELY

EACH DISEASE HAS A SPECIFIC CAUSAL AGENT

THE PHYSICIAN’S MAIN TASK IS TO REMOVE THE CAUSE
AND RELIEVING THE SYMPTOMS

THE CLINICAL METHOD AND THE CLINICIAN USUALLY
BECOMES AS AN OBSERVER AND THE PATIENT BECOMES AS
A PASSIVE RECIPIENT
THE ANOMALIES ENCOUNTERED BY
THE OLD PARADIGM
1. THE DISEASE ANOMALY: A LARGE PROPORTION OF
ILLNESSES CANNOT BE DIAGNOSED TO A SPECIFIC DISEASE
CATEGORY
2. THE SPECIFIC ETIOLOGY ANOMALY: NOT ALL THE
POPULATION WILL GET SICK FROM THE SAME AGENT
3. THE MIND/ BODY ANOMALY: MIND AND BODY WERE
SEPARATED
4. THE PLACEBO EFFECT AS A MIND/ BODY ANOMALY
5. PHYSIOLOGICAL PATHWAYS
6. NEW KNOWLEDGE OF THE IMMUNE SYSTEM
2. THE NEW PARADIGM IN MEDICINE
 DISEASE IS NOT SEPARATED CONCEPTUALLY FROM THE PERSON, NOR
THE PERSON FROM ENVIRONMENT
 ALL ILLNESSES AFFECT THE PATIENT AT MULTILEVELS
 THE TASK OF THE PHYSICIAN IS TO UNDERSTAND THE NATURE OF THE
ILLNESS ON ALL ITS LEVELS
 ALL LIVING SYSTEMS ARE OPEN SYSTEMS, IN THAT EXCHANGE BOTH
ENERGY AND INFORMATION ACROSS THE SYSTEM INVOLVES
INTERFACES OR BOUNDARIES
 SYSTEM HIERARCHY IN THE HUMAN BODY ARE MOLECULES, CELLS,
TISSUES, ORGAN SYSTEMS, NEUROENDOCRINE IMMUNE SYSTEMS,
PERSON, FAMILY, COMMUNITY, CULTURE AND SOCIETY.
3. FAMILY MEDICINE HAS EVOLVED FROM G.P
C. THE AGE OF G.P
AND
SPECIALIZATION
F.M
B. GROWTH OF
SPECIALIZATION
A. CHANGES
IN MORTALITY
AND
MORBIDITY
F. THE AGE OF
MANAGED CARE
E. CHANGING ROLE OF THE
HOSPITAL
G.P
D. NEW DEVELOPMENTS IN THE
BEHAVIORAL SCIENCES
A. CHANGES IN MORTALITY AND MORBIDITY
DEVELOPED COUNTRY




THE SUCCESSFUL CONTROL OF
THE MAJOR INFECTIOUS DISEASE
SEVERE ACUTE ILLNESSES
CHRONIC DISEASE
THE REDUCED MORTALITY
INCREASED THE
PROPORTION OF ELDERLY
PUBLIC HEALTH TO PRIVATE
HEALTH
DEVELOPING COUNTRY
 DOUBLE BURDEN OF
DISEASE
 COMMUNICABLE AND
NONCOMMUNICABLE DISEASES
(Behavioural causes e.x. life style,
smoking, abused etc)
CLEAN WATER, A BALANCED DIET AND GOOD HOUSING ARE
STILL MAJOR DETERMINANTS OF HEALTH
B. THE GROWTH OF SPECIALIZATION
SPECIALIZATION
(MEDICAL , SURGICAL)
 PUBLIC
NEEDS
GENERAL
PRACTITIONER
 SOCIAL
PRESSURES
PROFESSION
HEALERS
GEYMAN (1971), FAMILY DOCTOR/
PHYSICIAN IS:
1.
2.
3.
4.
GENERAL PRACTITIONER
A SPECIALIST ( GENERAL PRACTITIONER + 3
YEARS)
USA
GENERAL PRACTITIONER OR SPECIALIST
WHO PROVIDE HEALTH SERVICES WITH THE
BASIC PRINCIPLES OF FAMILY MEDICINE/
FAMILY MEDICINE APPROACH
INDONESIA
DEVELOPED GENERAL PRACTITIONER
D. NEW DEVELOPMENTS IN THE BEHAVIORAL
SCIENCES
• INSIGHTS INTUITIVELY
APPROACH TO PROBLEMS
ORGANIZED
• BEHAVIORAL SCIENCES HAS DIRECTED TO THE
PROCESS BY WHICH PEOPLE SEEK MEDICAL CARE, A
CRUCIAL FOR ALL PRIMARY PHYSICIANS
• IT’S MAKING US MORE AWARE OF THE
IMPORTANCE OF OUR BEHAVIOUR IN
DETERMINING OF THE QUALITY OF CARE
• IT HAS INCREASED OUR INSIGHTS INTO THE
DOCTOR – PATIENT, FAMILY RELATIONSHIP AND
BEHAVIORAL ASPECTS OF ILLNESS
NEW DEVELOPMENTS IN THE BEHAVIORAL
SCIENCES (CONT’D)
 IT HAS MADE US THINK ABOUT SOME OF THE
FUNDAMENTAL ASPECTS OF MEDICINE
( CONCEPTS OF HEALTH, DISEASE AND ILLNESS, THE
ROLE OF PHYSICIAN AND THE ETHIC OF MEDICINE)
 IT HAS BROUGHT TO OUR ATTENTION THE POOL OF
ILLNESS THAT NEVER REACHES THE MEDICAL
PROFESSION
 IT HAS INCREASED OUR KNOWLEDGE OF
BEHAVIORAL AND SOCIAL ECONOMIC FACTORS
INVOLVED IN THE CAUSATION OF DISEASE
20 %
20 %
10 %
50 %
Global burden of
disease, Murray &
Lopez, WHO, 1996
E. THE CHANGING ROLE OF THE HOSPITAL
THE COST OF INPATIENT
CARE HAS BECOME SO
PROHIBITIVE THAT
CRITERIA FOR ADMISSION
TO THE HOSPITALS so
strict
• FRAGMENTATION OF CARE
• FREQUENT CHANGES OF
PERSONNEL
• THE ANTITHESIS OF
INTEGRATED PERSONAL
MEDICINE
FOR THOSE WHO NEED CARE FOR A
VARIETY OF PROBLEMS OVER A LONG
PERIOD OF TIME, THE HOSPITAL IS A
MUCH LESS SATISFACTORY FORM OF
CARE
THE HOSPITAL
PROVIDES
SPECIALIZED
SUPPORT WHEN IT
IS NEEDED
WHAT ABOUT PRE AND POST
HOSPITAL CARE ? Who provides
them ?
F. MANAGED CARE AND THE AGE OF
INTEGRATION
TERTIARY LEVEL
SECONDARY
LEVEL
PRIMARY LEVEL:
FAMILY PHYSICIAN
/ GATE KEEPER
ECONOMIC FORCES
MANAGED CARE
(HMO- US)
THE OTHER HEALTH
PROFESSIONALS
AND
COMMUNITY SUPPORT
SERVICES
WHAT TYPE OF PHYSICIAN IS DEMANDED ?
Charles Boelen :
Family doctor is
NOT A
SOLUTION but
the bridge
between
hospital care
and public
health.
He is able to
help save costs
through being a
five stars doctor
CARE and CURE PROVIDER
DECISION MAKER
MANAGER OF
DECISION MAKER
HEALTH
CARE
RESOURCES
COMMUNITY LEADER
COMMUNICATOR
THE FIRST THREE OF CENTRAL VALUES, ARE ATTITUDES
THAT WE WOULD WANT TO INFECT ALL DOCTORS WITH:
• PATIENTS CENTRED CARE AND ATTENTION TO THE
DOCTOR-PATIENT RELATIONSHIP.
• HOLISTIC APPROACH TO THE PATIENT AND HIS
PROBLEMS THAT RECOGNIZES CONTRIBUTIONS TO ILL HEALTH AND WELL- BEING COME FROM NOT ONLY
PHYSICAL DISEASE BUT EQUALLY IF NOT MORE FROM
SOCIAL ECONOMY AND PSYCHOLOGICAL DIMENSIONS
IN THE PATIENT AS WELL AS FROM THE FAMILY AND HIS
COMMUNITY.
• EMPHASIS ON PREVENTIVE MEDICINE BECAUSE THIS HAS
GREATER LONG TERM IMPACT ON HEALTH STATUS THAN
CURATIVE MEDICINE.
THE NEXT THREE CENTRAL VALUES DEFINE
THE FAMILY DOCTOR’S WORK
• THE FAMILY DOCTOR LOOKS AFTER HEALTH
PROBLEMS THAT MAY BE INITIALLY UNCLEAR IN
TERMS OF SERIOUSNESS
• THE FAMILY DOCTOR LOOKS AFTER PEOPLE
ACROSS THE WHOLE SPECTRUM OF AGE GROUP ~
HE IS A SPECIALIST IN BREADTH
• THE FAMILY DOCTOR IS WILLING TO LOOK
AFTER THE PATIENT NOT ONLY IN THE
CONSULTING ROOM BUT ALSO IN THE HOME
AND OTHER SETTINGS AS WELL
THE PLACE OF FAMILY MEDICINE IN HEALTH
CARE: DIVISION OF LABOR
FIRST CONTACT CARE (GENERAL
PRACTITIONER/ FAMILY MEDICINE
SERVICE/ PUSKESMAS)
LOOKING AFTER PATIENTS
THAT COULD BE MANAGED
OUTSIDE THE HOSPITAL
Definition of Primary Care:
The setting within a health care system, usually in the patient’s own
community in which the first contact with the health professional occurs
The European Definition of General
Practitioners/Family Medicine, WONCA Europe, 2002
THE PLACE OF FAMILY MEDICINE IN HEALTH CARE:
WORKING TOWARDS UNITY FOR HEALTH
STAND ALONE ~
DANGER
INTEGRATION OF CLINICAL
ACTIVITIES ( TO INTEGRATE
WITH HOSPITAL BASED
DISCIPLINES: PAEDIATRICS,
INTERNAL MEDICINE,
GERIATRICS etc)
INTEGRATION
WITH PUBLIC
HEALTH
HAS THE ROLE OF INTEGRATING IN
THE MIND OF EVERY DOCTOR THE
BALANCE BETWEEN SPECIALIZATION
AND GENERALIST APPROACH IN THE
PATIENT CARE
INTEGRATION WITH SOCIAL
AND ECONOMIC
DEVELOPMENT OF THE
COUNTRY
INTEGRATING FAMILY MEDICINE’S EFFORTS
IN HEALTH CARE DELIVERY
1. GOOD PREVENTIVE CARE
2. GOOD ACUTE CARE
5. GOOD ELDERLY
CARE
3. GOOD CHRONIC DISEASE
CARE MANAGEMENT
4. GOOD STEP-DOWN CARE ~ IS
VERY IMPORTANT WITH THE
RISING COST OF ACUTE
HOSPITAL CARE AND THE
INCREASING NUMBERS OF
THE ELDERLY WHO TAKE A
LONGER TIME TO RECOVER
FROM MEDICAL ILLNESSES.
+
6. GOOD
DOMICILIARY CARE
7. GOOD PALLIATIVE
CARE
FAMILY MEDICINE IN INDONESIA
 THE CONCEPTS FIRSTLY REVEALED IN THE NATIONAL CONFERENCE
OF INDONESIAN MEDICAL ASSOCIATION IN 1980
 INDONESIA IS ONE OF WORLD ORGANIZATION OF NATIONAL
COLLEGE, ACADEMIC & ACADEMIC ASSOCIATION OF G.P/F.P
(WONCA) MEMBERS, REPRESENTED BY THE INDONESIAN COLLEGE
OF FAMILY PHYSICIANS (KDKI)
 NOW: THE INDONESIAN ASSOCIATION OF FAMILY MEDICINE (PDKI)
 INDONESIAN NEEDS FAMILY MEDICINE ORIENTED PRIMARY CARE
DOCTORS TO BE EFFECTIVE GATE KEEPERS IN THE HEALTH CARE
DELIVERY SYSTEM
REFERENCES
1. Mc Whinney. A textbook of Family Medicine. Third
Edition, Oxford New York, 2009. pp 5 -12.
2. Lee Gan, Azwar.A, Wonodirekso. Family Medicine
Practice. Singapore, 2004. Section 3 chapter 1 pp 24-5,
42-8
3. Azrul Azwar. Dokter Keluarga. Direktorat Jenderal Bina
Kesmas Departemen Kesehatan RI. Jakarta, 2002. pp
1-15.
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FOUNDATIONS OF FM