Family

Medicine

Foundation Courses
for the
FM Residency Training Programs
in the Philippines
 Academic Domains

8 EBM
1  Family Medicine
9 QA
Principles and
10 Research
Practice 11 Information
2  Primary and Technology
Secondary Care
3  Acute Care 12. Medical Ethics
and Professionalism
4  Preventive and 13. Legislation on Health
Wellness and the Family
5  Communication 14. Practice Management
and
and Relational Skills
Health Administration
6  COPC 15. Hospice and Palliatve
7  Occupational Care
Health and Safety
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 Matrix of
transmission personality
unit development
The Family as the Unit of Care
› Family Health Care
means_
›  taking
care of all individuals in the
family on a one by one basis,

›  dealing
with the family as object of
management

›  influencingfamily 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 Blended

Parent
 BASIC AREAS of FAMILY FUNCTIONS

• Reproduction / Child Rearing

Biologic • Nutrition / Health Maintenance / Recreation

• Financial Resources / Allocation

Economic • Financial Security

Educational • Teach values and inculcate attitude

• Model skills relating to other functions

• Natural development of personalities

Psychologic • Building healthy relationships
• Optimum psychological protection

Socio- • Socialization of children

cultural • 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 Ally
in the Patient’s Treatment

›  90%
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 Relationships
›  Self-help and accepting help
› Flexibility of family functions and roles
›  Crisis as a means of growth
›  Unity and support during hard times
›  Family unity, Loyalty and intra-family
Cooperation
The value of the ‘Family as a Unit Care’
›  Health
problems as isolated phenomena can
neither be understood nor successfully dealt
with

›  Treatmentas a unit yields

more certain a complete
diagnosis, better medical
outcome and benefits
with regard to prevention
 Step 3:
Step 1: Step 2: Learn to Assess
Understanding Family Structure
Recognize Normal Family and Function in
Family Structure Function 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:
1.  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 well-
structured FAMILY GENOGRAM for each patient
 YAP - ZALES FAMILY

Alvin, Marichu, 38
50

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

Crisantal, 4 Christian, 1
YAP- ZALES
April 18, 2015

I
Alvin, Marichu, 38
50
II
Mheilchie, 23 Eden, Alma Rose, 19 Marvin, 18 Rhea, Mark, 9
23 11
Very close Distant
III
Crisanta, 4 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
•  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
5.  Families communicate with each other
 FIRM RULES

Normal
Families RIGID

STRUCTURED

DISENGAGED SUPPORT & CONNECTED

AUTONOMY
INDIVIDUATION
& SEPARATED ENMESHED FAMILY
CLOSENESS
FLEXIBLE

CHAOTIC

ADAPTABILITY

MODIFIED TWO-DIMENSIONAL MODEL OF FAMILY FUNCTION

Normal families tend to fall within the shaded circle
 The Cycle of Family Function

Family in Stressful
Functional Life Event
Adaptation Equilibrium (1) (2)
(Functional or nurturing)
[Coping] (5)
Resources
Adequate Family in
(4) Disequilibrium (3)
Resources Inadequate
(6)
Crisis (7) Extra-Familial
resources (8)
Maladaptation
Pathologic Defense Mechanism
(9)

Pathologic Stressful
Terminal
Disequilibrium Life Event
Disequilibrium
(10) (1)
(12)
SMILKSTEIN’S CYCLE OF FAMILY FUNCTION
A model for family response to stressful events
CHECKLIST TO ASSESS FAMILY FUNCTION
1.  How many are there in the family?
2.  Who lives at home?
3.  In what phase of Family Life Cycle is the family?
4.  What problems do this phase raise for them?
5.  What major problems has the family had in the past?
6.  Does the family feel these problems were dealt with
satisfactorily?
7.  Is there any history of alcoholism, drug abuse or
dependency?
8.  How are major decisions made in the family & by whom?
9.  Are the in-laws & relatives helpful? Do they create
problems for the family?
10.  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.  What community resources has the family used?
Would the members use them again?
12.  Has this family not used community resources at times
when they would have been appropriate?
13.  What does each parent expect of each child, both on
day to day basis & for the future?
14.  What does each member of the family have to do to
get attention?
15.  How much tolerance for individual differences is there in
the family?
16.  What are the goals, interests, and values of the family?
17.  Do all the family members work together toward these
goals?
18.  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.  Family Genogram
II.  Family Circle
III.  Family APGAR by Smilkstein
IV.  FACES (Family Adaptability and
Cohesion Evaluation Scale)
V.  FES (Family Environment Scale) by Moos
VI.  Clinical Biography and Life Events
VII.  SCREEM (Social, Cultural, Religious,
Economic, Educational and Medical)
VIII.  DRAFT (Draw-a-Family Test)
IX.  Family Assessment Model
X.  Family Mapping
I. Family Genogram
›  Advantages, uses and information
derived:
o  Records names and roles of each member
o  Separates extended family into several households
o  Documents medical problems of each member of
the family
o  Documents significant dates in the family history
o  Reveals more subtle information about the family

›  Disadvantages:
o  Limited role in assessing family functions
o  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
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Ches
ter

Gina

Tita c
i
Mav Ate
Vi

Wal
ter
III. Family APGAR
›  An assessment tool originally described
by Smilkstein which is applied in basic
situations like
1.  In direct involvement in patient care
2.  In providing information while patient is
being treated
3.  In a family crisis, and in
4.  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
APGAR QUESTIONNAIRE Almost Some Hardly
always of the Ever
Time
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 Then add up the points and interpret
as to the following:
the following: scheme
8 – 10 pts Highly functional
Almost always 2 points 4 – 7 pts Moderately dysfunctional
Some of the time 1 point 0 – 3 pts Severely dysfunctional family
Hardly ever 0 point
 IV. FACES
Family Adaptability And
Cohesion Evaluation Scale
› ASELF-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  Does not measure the person’s inherent
ability to draw but how he pictures his
family members
Ø  The following are important in the
evaluation and interpretation:
1.  Configuration of the father, mother, siblings
2.  Sequence of succession
3.  Quality of lines
4.  Significant details like omission of some parts
Ø  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 over-
involved 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     Social    
systems  
-­‐ Family  
Psychological  
-­‐ Community  
Emotional  
-­‐ National  
Aspect  
-­‐ Global  
BPS Model background
›  Shifting of paradigms

›  Methodology

›  Hierarchy of Natural Systems

›  Typology 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]
›  Unityof 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 SOCIAL
Culture/Ethnic
Community Conceptual
Family Framework
Personal for Clinical
Body Systems
Organs Reasoning:
ANALYSIS of DATA &
Tissues
SYNTHESIS of
Cells SOLUTION
ORGANISMIC
Organelles
Molecules
Atoms
Subatomic
 60 4/1/19

›  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
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 Chronic illness Terminal illness
illness (life-limiting phase)
(crisis (readjustment phase)
phase)

• Family routines • Prolonged fear • Death is inevitable

are suspended and anxiety • Devastating
• High emotions • High incidence of emotions – grief,
illness in other mourning, shock, or
• Initial coping or
family members overwhelming
adaptation anxiety
• Over-indulgence • Family’s reactions –
• Doctor’s role – towards the sick members may be
facilitate healthy member resulting drawn close
response, to overwork together or start to
acceptance of stay apart ending
diagnosis and • Doctor’s role – into family discord
recognize encourage and breakdown
dangers ventilation of
(delayed or feelings, give • Physicians’ roles:
prolonged reassurance and • Assist patient and
reaction) reinforce care his family
• Provide quality
care
 HEALTH

REACTION
ONSET TO
DIAGNOSIS

FAMILY
ADJUSTMENT MAJOR
TO PERMANANCY THERAPEUTIC
OF OUTCOME EFFORT

EARLY
ADJUSTMENT
TO OUTCOME

SYSTEM
 2. PRIMARY AND SECONDARY CARE
[use of the Biopsychosocial Approach]
›  Effectiveness in seeing undifferentiated patient
›  Recognize the various modes of presentation
of illness
›  Adequate knowledge of diseases of various
age groups
›  Recognizethe various factors that impact on
the health/illness of patients
2. PRIMARY AND SECONDARY CARE
[use of the Biopsychosocial Approach]
continuing, comprehensive
›  Provide
and personalized care to patients with
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 RESEARCHER
Family focused care the FAMILY Evidence-based
PHYSICIAN medicine user
“generalist”

MANAGER ADVOCATE
Coordinator of care
and resources “population at risk”
ALMA ATA DECLARATION, 1978
 NATURAL  HISTORY  OF  ANY  DISEASE  PROCESS  IN  MAN  
Pre-­‐pathogenesis  period   Period  of  pathogenesis  
   
   
   
Before  man  is  diseased    
  THE  COURSE  OF  DISEASE  IN  MAN  
Interaction  of:   DEATH  
   
Disease     Human   Chronic  
 
agent   host   CLINICAL HORIZON    
  State  
  Early  pathogenesis  
 
Advanced
Discernible Disability  
ENVIRONMENTAL  FACTORS   Interaction  of  HOST   early disease disease Convalescence  
which  produce   and  STIMULUS                                                                                                                                        recover  
DISEASE  STIMULUS    
 
 preventive health behavior

the HEALTH BELIEF MODEL

Perceived Perceived Likelihood

Susceptibility Perceived Benefits of taking
to health Threat of of/Barriers the
problem or a health to a preventiv
Perceived problem preventiv e health
Seriousness e action action
 NATURAL  HISTORY  of  any  DISEASE  PROCESS  in  HUMAN  

Pre-­‐pathogenesis  period   PERIOD OF PATHOGENESIS

   
   
   
Before  man  contracts    
disease   THE  COURSE  OF  DISEASE  IN  MAN  
interaction  of_   DEATH  
 
 
Disease     Human   Chronic  
 
agent   host   CLINICAL HORIZON    
  State  
  Discernible Advanced
Early  pathogenesis  
  early
ENVIRONMENTAL  FACTORS   disease Convalescence   Disability  
Epidemiologic  Triad   disease
(disease  stimulus)                        dynamics  
 
RECOVERY RECOVERY RECOVERY RECOVERY

TERTIARY
primary
prevention
secondary
PREVENTION
prevention
Key POINTS in the

levels of prevention:
1.  Primary Prevention and Predisease
›  Health Promotion
›  Specific Protection
2.  Secondary Prevention and Latent Disease
›  Early diagnosis
›  Prompt treatment
3.  Tertiary Prevention and Symptomatic Disease
›  Disability Limitation
›  Rehabilitation

71
Monday, April 1, 19
Stage of Level of Prevention Appropriate Response
Disease
Leavell’s Levels of Prevention
PREDISEASE
No known risk Primary prevention Health Promotion – healthy changes in
factors lifestyle, nutrition, and environment

Disease Primary prevention Specific Protection – recommended

susceptibility nutritional supplements, immunizations,
occupational and automoblie safety measures

LATENT DISEASE Secondary Screening (populations)

prevention Case Finding (individuals)
Prompt treatment
SYMPTOMATIC
DISEASE
Initial care Tertiary prevention Disability Limitation – medical and surgical
treatment to limit damage from the disease and
institute primary prevention measure

Subsequent Tertiary prevention Rehabilitation – identify and teach methods

care to reduce physical and social disability 72
Based on the concept of prevention by
LEAVELL, the key messages are:
›  Allof 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