Dr. JAWAHER AL-AHMADI MB. ABFM. SBFM. MSc.

Objectives
To list and explain the different level of health care To know developmental history of the specialty To define family medicine and primary care To list and explain the Principles of family medicine To understand the characteristics and role of family physician To know Innovations in family medicine To know misconception regarding family medicine

Content

Developmental history of the specialty Family medicine and Primary care Innovations and misconception in family medicine

Levels of health care

Primary

heath care . Primary heath care centers health care General hospital health care University & highly specialized hospital

Secondary

Tertiary

Terms of Reference

Sciences
General medicine Primary care Primary care medicine Family medicine

Practitioners General practitioners Primary care practitioners Family practitioners

Sites of practice General practice PHC Family practice General and polyclinics

Overview
Modern

medicine had fragmented the health care delivery system Emergence of major specialties Fragmentation of the professions Technology rather than human oriented approach Rapid return of the generalist physician who would give comprehensive, personalized care was urged

The trend toward specialization gained momentum through the 1950s, and fewer physicians entered general practice. In the early 1960s, leaders in the field of general practice began advocating a seemingly paradoxical solution to reverse the trend and correct the scarcity of general practitionersthe creation of still another specialty. These physicians envisioned a specialty that embodied the knowledge, skills, and ideals they knew as primary care.

In 1966, the concept of a new specialty in primary care received official recognition in two separate reports published 1 month apart. The first of these was the report of the Citizens' Commission on Medical Education of the American Medical Association, also known as the Millis Commission Report. The second report came from the Ad Hoc Committee on Education for Family Practice of the Council of Medical Education of the American Medical Association, also called the

Willard Committee (1966)

Three years later, in 1969, the American Board of Family Practice (ABFP) came into being as the 20th medical specialty board. The name of the specialty board was changed in 2004 to the American Board of Family Medicine (ABFM)

The Origins Of Family Medicine

Changes in mortality & morbidity Successful control of infectious diseases Increasing incidence & prevalence of chronic diseases Accidents Behavioral disorders Newly emerging and re-emerging diseases Population growth Increased life span The changing role of the hospital. Managed care and the age of integration.

New Developments In The Behavioral Sciences

New

insights Better understanding of human behaviors and needs. Better understanding of the roles of family & society in the health care system

Family Medicine

Family medicine 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 family medicine encompasses all ages, both sexes, each organ system, and every disease entity.

Family Physician

The family physician is a physician who is educated and trained in the discipline of family medicine. Family physicians possess unique attitudes, skills, and knowledge that qualify them to provide continuing and comprehensive medical care, health maintenance, and preventive services to each member of a family regardless 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 as each patient's advocate in all health-related matters, including the appropriate use of consultants, health services, and community resources ( AAFP, 1993 ).

WONCA definition of family doctor

The World Organization of Family Doctors (World Organization of National Colleges, Academies, and Academic Associations of General Practitioners and Family Physicians [WONCA]) defines the family doctor in part as

the 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 )

Primary Care / Family Practice

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 an undiagnosed sign, symptom, or health concern (the undifferentiated patient) not limited by problem origin (biological, behavioral, or social), organ system, or gender.

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

It is highly personalized first-contact care, serving as a point-of-entry for the patient into the health care system; It includes continuity by virtue of caring for patients over a period of time, both in sickness and in health; It is comprehensive care, drawing from all the traditional major disciplines for its functional content;

It serves a coordinative function for all the health-care needs of the patient; It assumes continuing responsibility for individual patient follow-up and community health problems; and It is a highly personalized of care.

WHO IS A PRIMARY CARE PHYSICIAN ?

A

primary care physician is a generalist physician who provides definitive care to the undifferentiated patient at the point of first contact and takes continuing responsibility for providing the patients care. Primary care physicians devote the majority of their practice to providing primary care services to a defined population of patients.

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 a sustained partnership with patients, in the context of family and community.

Why is this?
Preventive services are more consistently delivered Chronic diseases, such as asthma, cardiovascular disease, and diabetes, are better managed Acute problems are diagnosed and treated earlier

Primary care
Primary care providers include Family physicians General internists General pediatricians Family nurse practitioners (and some adult care and pediatric nurse practitioners) some physician assistants Gynecologists

Primary care (Advantages)

Physicians care is aimed at preventing adverse, costly events such as hospitalizations and further morbidity, they are well positioned to address the major national health priorities

Role of Primary Care In Addressing Health Care Priorities

An extensive variety of common, rare, and undifferentiated problems are managed in primary care. Management included a diagnostic process where the patient presents with new symptoms and leaves with a new or provisional diagnosis. Prevention is practiced broadly in primary care visits, and not just during physicals. During 32% of illness visits, the family physician delivers at least one preventive service

CASE
Mr. Ahmed is a 48-year-old gentleman who lives with his wife, Sara, and their 6-year-old son, Ali. He has recurrent abdominal pain and a chronic cough. He self-medicates with overthe-counter antacids and cough syrup. Sara, is a housewife , her most persistent complaint is chronic pain in her shoulders, neck, and upper back. Several months ago, when in the emergency

Their son, Ali, receives his immunizations at polyclinic. He has asthma and is occasionally brought to an urgent care clinic when his symptoms get bad

Questions
What

options exist to provide this family with the care that is both affordable and in line with principle of good primary care practice ? are those principles?

What

Would

this family be better served by a primary care based health system or a specialty based care?

Health system in KSA

Every country has to develop a health system capable of meeting the priority health needs Area of 2,240,000 Sg. Km. 16 million. Density of 6 persons/Sg. Km.

45% Lives in large cities Hajj & Omra Climate

ESTABLISHMENT OF PHC Till the year 1399 H, health services were delivered in terms of Curative:
Hospital Dispensaries Preventive: Health offices MCH Centres

ESTABLISHMENT OF PHC The World Health Assembly decided in 1977 that the main social target for Governments & WHO is: HEALTH FOR ALL BY THE YEAR 2000 Alma Ata Declaration 1978

PRIMARY HEALTH CARE

Medical Students CME, CPD

Medical Research

Political Upheaval, War Natural Disasters

Medical Insurance Doctors Employer Doctors Employee

Managed Care

Other Doctors
Hospital Paramedics Health Promotion Disease Diagnosis

International Community

National Community Laboratories

Doctors Family

Clinic Management

DOCTOR
Disease Prevention

PATIENT
Therapy Pharmaceutical Industry

Press, Media

Public Health Practice Management MDO Medical Council

The LAW

Patients Family, Culture, Religion

Patients Work, Employer

Alternative Medicine

Patient Organisation
Medical Charities

Government Bodies

THE MEDICAL ECOSYSTEM - Enlarging Circle of Influence

ESTABLISHMENT OF PHC

Ministerial Decree No. 2571/1459/50 dated 17.8.1400 (1980) ESTABLISHMENT OF HEALTH CENTRES:

Health offices MCH centres Dispensaries

PHC CENTRES development was initiated in 1404

DEFINATION OF PHC

Essential health care Based on practical, scientifically sound and social acceptable methods & technology Accessible to individuals & families It is their first level of contact Cost that the community & country can afford It forms an integral part for both the countrys health system & the overall social & economic development

ELEMENTS OF PHC

PROMPOTIVE :

Health Education Food supply & proper nutrition Maternal & Child care

PREVENTIVE: Immunization Prevention & control of locally endemic diseases Adequate supply of safe water & basic sanitation

ELEMENTS OF PHC

CURATIVE:

Treatment of common diseases & injuries Provision of essential drugs.

ADDITIONAL ELEMENTS: Dental care Mental health School health Home health care

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

PHC PRINCIPLLES
Community participation: - Social awareness & community self reliance. - The people has the right and duty to participate in the process for the improvement and maintenance of health. Support from higher levels of care : - Hospitals has to share the social goal of making essential health services. - Referral

Principles of Family Medicine

Continuity

of care Comprehensiveness Coordination of care Community orientation Communication skill

Principles of Family Medicine

Cost

effectiveness Prevention focus Evidence-based practice Biopsychosocial, life-cycle perspective Family-centeredness

Continuity Of Care

The average family medicine patient has seen the same physician 20 times over the previous 5 years This provision of care by the same provider over time is called continuity of care Continuity of care facilitates implementation and tracking of screening tests and other services that should be repeated periodically Continuity visits also provide opportunities to reinforce a message with repetition

Comprehensiveness
A Family Physician manages between 85% to 90% of the patient who present in the primary care. Provision of a wide variety of services covering the majority of patient needs is termed as

comprehensiveness of care

The family physician must be comprehensive trained to acquire all the medical skills necessary to care for the majority of patient problems including, each specialty according to its prevalence.

Comprehensive Care

Promotive Preventive Curative Rehabilitive

Coordination of care

During 10% of office visits, a referral is made to a medical specialist, mental health provider, physical therapist, social worker, or other health professional Being aware of the variety of services available making appropriate request for consultations or referrals Collecting and interpreting results of the studies and specialist visits Advising when additional care is needed Gate keeping models/coordination of care

The family physician facilitates the patients access 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 of both upon the patients way of life. Millis Commission Report.

Case
Mr. F, a 60-year-old patient in your practice, presents to the emergency department with a bowel obstruction. The ensuing work-up reveals colon cancer as the cause, and he undergoes bowel resection with multiple positive nodes but no distant metastases identified. You refer him to Dr. G, a local oncologist, who recommends aggressive therapy

What should family physician do with this patient?

Community Orientation
medical practice requires this orientation, because what happens in homes, schools, worksites, health departments, and elsewhere in the community can have profound effects on individual health and quality of life. Good

Prevention focus

Preventive care is the most common reason patient's visit a family physician's office Premarital care Prenatal care Well baby checkups Well child examinations Adolescent care Routine adult physicals Elderly care Pre-employment physicals Visits as preparation for international travel

Prevention focus
Measure to reduce disease risk Immunizations Measure to prevent morbidity in patient who have established disease Prevention of secondary disability in people with disease related morbidity

Evidence-Based Medicine

An evidence-based approach means that the clinician has made the effort to identify the strongest, most valid studies, is able to change his or her mind about a test or treatment when the evidence supports a change in practice.

Evidence-Based Medicine

An evidence-based approach means that the clinician has made the effort to identify the strongest, most valid studies, is able to change his or her mind about a test or treatment when the evidence supports a change in practice.

Quality driven

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

Biopsychosocial, Life-Cycle Perspective

Effective primary care physicians view patients from a broad perspective, taking into account physiology, physical illness, emotional health, and the social, occupational, and environmental context within which the person lives. Biopsychosocial approach is important because health and illness behavior are strongly colored by the personality and environment of the patient.

Biopsychosocial, Life-Cycle Perspective

For example, whether or not a patient will actually take a prescribed medicine will depend on many factors
Medication's cost The experience of the person and others he or she knows with similar medical treatment Interaction between side effects and the person's needs (e.g, Alertness or sexual potency)

Family Orientation
Quality primary care must take into account the family context By family we mean the entire range of relationshipswhether or not by blood or marriagethat can comprise a patient's close social network Most health behaviors and illness episodes involve some connection with the patient's social support network

Family Orientation
Seventy percent of patients seen in these family physician visits have another family member seeing the same physician. In 18% of visits, care is provided to another family member in addition to the identified patient.

Family Orientation
The man who develops a chronic illness that will require him to perhaps eat differently or alter his recreational patterns. As more sophisticated electronic information systems and further maturation of applied genetics, it is likely that the importance of a family orientation will increase

Cost Effective Care

Knowing their patients well family physician are capable of: Assessing the nature of their patients health problem more rapidly and accurately. Using time as an ally in diagnosing less urgent problems. Ensuring the most logical and economical management. Controlling magnification of simple problem. Ordering fewer test.

Accessibility
Services must be available when needed and should be within geographic proximity

PERSONALIZED CARE
It is much more important to know what sort of patient has a disease than what sort of disease a patient has. Family practice emphasizes consideration of the individual 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 the patients and their families, and serves as an advisor and confidant to the family- both individually and collectively

Home Care Home visits Outreach activities

A strong sense of responsibility for the total, ongoing care of the individual and the family during health, illness, and rehabilitation Compassion and empathy, with a sincere interest in the patient and the family A curious and constantly inquisitive attitude.

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

A desire for frequent and varied intellectual and technical challenges The ability to support children during growth and development and during their adjustment to family and society
The ability to assist patients in coping with everyday problems and in maintaining stability in the family and community

The capacity to act as coordinator of all health resources needed in the care of a patient A continuing enthusiasm for learning and for the satisfaction that comes from remaining current through continuing medical education The ability to maintain composure in times of stress and to respond quickly with logic, effectiveness, and compassion.

A desire to identify problems at the earliest possible stage (or to prevent disease entirely) A strong wish to maintain maximum patient satisfaction, recognizing the need for continuing patient rapport

 The

skills necessary to manage chronic illness and to ensure maximal rehabilitation following acute illness
appreciation for the complex mix of physical, emotional, and social elements in holistic and personalized patient care

An

A feeling of personal satisfaction derived from intimate relationships with patients that naturally develop over long periods of continuous care, as opposed to the shortterm pleasures gained from treating episodic illnesses A skill for and commitment to educating patients and families about disease processes and the principles of good health

A truly comprehensive primary care (family) physician adequately

Manages acute infections. Biopsies skin and other lesions. Repairs lacerations. Treats musculoskeletal sprains and minor fractures. Removes foreign bodies. Treats vaginitis and provides obstetric care. Care for the newborn infant. Gives supportive psychotherapy. Supervises or performs diagnostic procedures.

Management of an illness involves much more than a diagnosis and an outline for treatment . It requires : Awareness of the factors aiding or hindering recovery from illness. Consideration of religious beliefs; social, economic, or cultural problems; personal expectations; and heredity. The outstanding clinician recognizes the effects that spiritual, intellectual, emotional, social, and economic factors have on a patients illness.

Illness Behavior
Factors Affecting Illness Behavior

Gender

Symptom presentation

Age
Race

Lay beliefs
Social Class

Learned behavior
Accessibility to health services

Previous experience
Trigger factors Locus of control

The health belief model

Perceived vulnerability Health motivation

Perceived costs and benefits

Perceived seriousness

The family physicians ability to confront relatively large numbers of unselected patients with undifferentiated conditions and carry on a therapeutic relationship over time is a unique primary care skill. The early identification of disease while it is in its undifferentiated stage requires specific training and is not a skill that can automatically be assumed by someone whose training has been mostly in hospital intensive care units.

Communication Skills

Who is the patient?!

Interpersonal Skills
One of the foremost skills of the family physician is the ability to effectively utilize the knowledge of interpersonal relations in the management of patients. This powerful element of clinical medicine is perhaps the specialtys most useful tool.

To relate well to patients, a physician must:

Develop compassion and courtesy. Establish rapport. Communicate effectively. Gather information rapidly and to organize it logically. Identify all significant patient problems and manage them appropriately. Listen , observe patients and detect nonverbal clues. Motivate people.

Case Discussion
The

case of the Mr.Ahmed family illustrates how psychosocial, environmental, and biomedical factors interact, and how understanding all of them is essential to making an accurate diagnosis and implementing effective treatment. Given that history, and his chronic cough, inquiry about his smoking history would be important.

Saras symptoms are highly suggestive of fibromyalgia, a common musculoskeletal disease that invariably requires psychosocial, biomedical, and environmental approaches to effectively treat. Her history is highly suggestive of type 2 diabetes, the diagnosis and treatment of which are likely to have been delayed .

Ali receives adequate preventive care but does 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 care services is likely to be contributing to his asthma morbidity.

Primary care versus subspecialty based care.

The supply of primary care physicians was significantly associated with lower all-cause mortality, whereas a greater supply of subspecialty physicians was associated with higher mortality. In contrast, sub specialist-focused care tends to lead to higher costs and poorer health outcomes.

Innovations in primary care

Increased

us of the Nurse practioners, Physicians Assistants, and Office Medical Assistants Electronic Health Records Electronic communication with patient Home care practices

Innovations in primary care

Open

Access scheduling Outcome based management of chronic diseases Group visits

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 always knows more than the generalist. By specializing one can eliminate uncertainty.

Misconceptions About The Roles Of Generalists & Specialists (contd)

Only

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

Final Message & Conclusions

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