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David E. Newton, MD, MS, DABFP Family Medicine Course, Semester VIII Community Medicine Department PSPD/UNEJ 2005
I. Definition of Family Medicine Family Medicine is the body of knowledge and skills that constitute the medical discipline which provides continuing, comprehensive care in a personalized manner to patients of all ages and to their families, regardless of the presence of disease or the nature of the presenting complaint. The scope of family medicine integrates the biological, clinical, and behavioral sciences, and encompasses all ages, both sexes, each organ system, and every disease entity. II. Primary Care Medicine A. Description 1.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 (biologic, behavioral, or social), organ system, or gender. Current specialties, which are included by this definition, are Family Medicine, General Internal Medicine, and General Pediatrics. Primary care includes diagnosis and treatment of acute and chronic illnesses, health promotion, disease prevention, health maintenance, counseling, and patient education. 2. Primary Care is a form of delivery of medical care that encompasses the following functions: 1) It is “first-contact” care, serving as a point-of-entry for the patient into the health care system; 2) It includes continuity by virtue of caring for patients over a period of time, both in sickness and in health; 3) It is comprehensive care, drawing from all the traditional major disciplines for its functional content; 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 problems; 6) It is a highly personalized type of care.
B. Training Requirements for Primary Care 1. Training must be broad and comprehensive. Research conducted by Rivo, et al. in 1994 regarding the common conditions and diagnoses that primary care physicians should be competent to manage, recommended that primary care specialist residency training include at least 90% of the key diagnoses confronting primary care physicians. By comparing training programs for various specialties, this goal was met only by Family Medicine (95%), General Internal Medicine (91%), and Pediatrics (91%) but not by OB/GYN (47%), Emergency Medicine (42%), or others. III. Important Characteristics and Functions of the Family Physician A. Continuing Responsibility 1. Enables the FP to detect early signs and symptoms of organic disease and differentiating it from a psychological problem 2. Intimate knowledge of the patient and his/her family and community background over time provides insight that helps the FP manage problems arising from emotional and social conflicts. 3. Observation of a patient’s long-term pattern of behavior and responses to stressful life situations, such as adjustment to puberty, employment, marriage, having children enables the FP to recognize the pattern of response in a given patient and how that influences the presentation of symptoms in a patient and ability of the patient and family to cope with illness and other stresses. This can help prevent the physician from over or under reacting to a patient’s complaint based on the FP’s knowledge of that patient. B. Personalized Care “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 (1904) 1. FP’s must care for people by showing compassion for his/her discomfort. Compassion means co-suffering to some extent with the patient. A compassionate physician gives advice to patients without humiliating them. 2. Family Medicine emphasizes consideration of the individual patient in the full context of his/her life, rather than the episodic care of a presenting complaint. 2. According to research performed by Tumulty (1970) on patient’s attitudes toward physicians, a “good physician” was described as one who (1) shows genuine interest in them; (2) thoroughly evaluates their problem; (3) demonstrates compassion, understanding and warmth; and (4) provides clear insight into what is wrong and what must be done to correct it.
C. Quality of Care 1. Primary care, to be done well, requires extensive training specifically tailored to problems frequently seen in primary care. These include the early detection, diagnosis, and treatment of depression; the early diagnosis of cancer (especially of the breast and the colon); the management of gynecologic problems; and the care of those with chronic or terminal illness. 2. The physician must place foremost the patient’s well being over the potential for economic gain for the physician. Doctors who spend less time with patients, who listen less to their complaints, can see more patients and make more money in the process but sacrifice the quality of patient care in the process. A physician must work efficiently to care for the needs of his/her patients but he/she must also avoid compromising the quality of care as a result. 3. The World Health Organization, at the 48th World Health Assembly (1995), urged member states, in order to improve the quality of health care in member countries, “to support efforts to improve the relevance of medical educational programs and the contribution of medical schools to the implementation of changes in health care delivery, and to reform basic education to take account of the contributions made by general practitioners to primary health care-oriented services.” 4. The Joint WHO-Wonca Conference of 1994 urged an increase in public funds to train more family doctors: “Given people’s needs for quality primary care services, countries should move towards a system in which a majority of practicing physicians are family doctors. To attain this goal, public funding should be shifted to train more family doctors and other community-based primary care and public health providers and fewer specialist physicians.”
D. Cost-Effective Care 1. “The higher the primary care physician-to-population ratio in a state, the better most health outcomes are.” (Starfield, 2000). 2. A high concentration of specialists, fee-for-service payment, patient self-referral directly to specialists, practice of specialties by physicians who have not gone through the specialty certification process, and high dependency on specialists for primary care all contribute to a higher cost of health care. 3. Expense and wastefulness multiplies when a patient self-diagnoses his or her problems or selects his or her own specialist rather than developing a firm and ongoing relationship with a family physician. The
most efficient and cost-effective system involves a single personal physician who ensures the most logical and economical management of a problem. 4. Specialists generally treat their patients more resource intensively than do generalists, resulting in increased cost of care. (Cherkin, et al., 1987) E. Comprehensive Care 1. The Family Physician must be trained comprehensively to acquire all the medical skills necessary to care for the majority of patient problems. The greater the number of skills omitted from the family physician’s training and practice, the more frequent is the need to refer minor problems to another physician. 2.Family Medicine is a comprehensive specialty involving varying depths of knowledge in many disciplines. 3. A physician specializing in only one discipline will have a much shallower base in comprehensive medicine and a much greater depth in the chosen discipline. The subspecialist (i.e. for one organ system) is an excellent consultant but is not trained and cannot function effectively as a primary generalist. 4. The Family Physician’s 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. 5. The skilled family physician will have a higher level of tolerance for uncertainty than will her or his consultant colleague. F. Interpersonal Skills 1. In the past, physicians have been perceived by patients as lacking the understanding of and compassion regarding patients’ personal anxiety and feelings important to the patient’s comfort and recovery from illness. 2. Family medicine emphasizes the integration of compassion, empathy, and personalized concern to a greater degree than does a more technical or taskoriented specialty. 3. The patient should be viewed as a person in distress who needs to be treated with concern, dignity, and personal consideration. 4. He or she has a right to be given some insight into his or her problems, a reasonable appraisal of the potential outcome, and a realistic picture of the emotional, financial, and occupational expenses involved in his or her care. 5. To relate well to patients, the physician must be able to establish rapport and to communicate effectively, gather information rapidly and to organize it logically, able to listen, have the skills necessary to motivate people, and the ability to observe and detect nonverbal cues. These qualities will increase patient compliance and satisfaction.
G. Diagnostic Skills 1. The family physician must be, above all, an outstanding diagnostician. Diagnostic skills must be honed to perfection. 2. Symptoms seen by primary care physicians are often vague and nondescript, with signs being either minimal or absent. 3. To the experienced physician, one symptom will be more suspicious than another because of the greater probability that it signals a potentially serious illness. 4. Diagnoses are frequently made on the basis of probability, which depends on the incidence of the disease relative to the symptom seen in the physician’s community during a given time of year. 5. An accurate history is the most important factor in arriving at an accurate diagnosis because symptoms may be the only obvious feature of an illness in it’s early stages when first seen by the family physician. H. Coordinator 1. The family physician, by virtue of his/her breadth of training in a wide variety of medical disciplines, has unique insights into the skills possessed by physicians in the more limited specialties. 2. The family physician is best prepared to select specialists whose skills can be applied most appropriately to a given case, as well as to coordinate the activities of each, so that they are not counter-productive. 3. The family physician not only facilitates the patient’s access to the whole health care system but also interprets the activities of the system to the patient, explaining the nature of the illness, the implication of the treatment, and the effect of both on the patient’s way of life. 4. The family physician maintains effective communication among those involved with a patient’s care as well as functions as the patient’s advocate. 5. This ability to orchestrate the knowledge and skills of diverse professionals is a skill to be learned during training and cultivated in practice. IV. The Practice of a Family Physician A. Broad spectrum of patient type 1. The specialty of Family Medicine emphasizes training in ambulatory care skills in an appropriately realistic environment, using patients representing a cross-section of a community and incorporating those problems most frequently encountered by physicians practicing primary care. 2.Data accumulated in the United states and Great Britain of adults experiencing illness or injury in an average month shows that out of a population of 1000 persons, 250 will consult a physician. Of these, 5 will
be referred for consultation to another physician and nine will be hospitalized—eight in a community hospital and one in a university hospital. 3. Students exposed to patients in a university hospital only will not be trained to recognize and treat the most commonly encountered illnesses presenting to a primary care physician (Figure 1-2).
4. Table 1-1 shows the 20 most common symptoms or reasons prompting office visits to a primary care physician in 1991.
5. The principal diagnoses resulting from these visits can be found in Table 1-2.
6. Most primary care visits arise from patients requesting care for relatively uncomplicated problems, many of which are self-limiting but cause the patients concern or discomfort. 7. The typical family practice physician in the US cares for 1500-3000 individuals, two thirds of which will be seen at least once each year. 8. Generally female patients present to the doctor more frequently than do males. See Figure 1-3.
8. Family physicians who admit to hospitals average 16 hospital visits per week. Those in rural practice average more hospitalized patients than do their colleagues in urban settings. V. WHO/WONCA Conference 1994 A. 21 Specific Recommendations 1. Recommendation #1 •“Fundamental changes must occur in health care systems to make them more equitable, cost effective, and relevant to people’s needs. The family doctor should have a central role in the achievement of these goals by being highly competent…” 2. Recommendation #9 •“Everyone should have a primary care provider…A specifically trained family doctor can respond appropriately to most of the problems that most people have most of the time. Whenever possible, family doctors should be used exclusively as doctors of first contact.” 3. Recommendation #14 “Medical education should respond…by training doctors who, in sufficient numbers, are capable of providing equitable, relevant, quality, and cost effective medical care.” 4 4. Recommendation #15 •“Formal recognition of Family Medicine as a special discipline in medicine—already accepted in many countries—should now become universal.” 5. Recommendation #16 •“The aim of basic medical education should be to produce graduates capable of undertaking further specific training in any chosen discipline—including family medicine. Basic medical education alone is insufficient training for family doctors. Competency in family medicine requires postgraduate training.” 6. Recommendation #17 •“Every medical school should have a department of family medicine.” 7. Recommendation #18 •“Every country should aim to establish programs of specific training in family medicine which should follow basic medical education…” VI. Status of Family Medicine Education in Asia
A. Family Medicine Education in the Asia Pacific Region: A Workshop organized by WONCA Asia Pacific Working Party On Education and The Philippine Academy of Family Medicine Manila, Philippines, 1993 1. Recommendations for Residency Programs in Family Medicine a. Teaching Settings •Both hospital setting and clinic setting are necessary b. Duration •Three years –1 year hospital + 2 years clinic –Or –2 years hospital + 1 year clinic c. Terminal Assessment •Needed for certification and tests for knowledge, skills and attitudes –Written questions –Clinical exam with case scenarios –Practice log –Oral examination B. Residency Programs in Asia • Philippines •Japan •China •Hong Kong •Sri Lanka •Taiwan •Singapore •Korea •New Zealand •Australia 1. Philippines--3 Year Program •Family Medicine Clinic 3 afternoons/wk •Emergency Med 24hrs/ 3-6days •Community Med 3 mos •Pediatrics 4-6 months •Internal Medicine 4-6 months •OB/GYN 4-6 months •Surgery 4-6 months •Psychiatry 1-2 months •Radiology, Opthalmology 1 month 9
2. Korea—3 Year Program •Family Medicine
1 month 1-6 months
6 months 7 months 4 months 3 months 8 months
•Internal Medicine •Pediatrics •Surgery •ENT, OB/GYN, Opth
3. Taiwan—3 Year Program •Internal Medicine •Pediatrics •OB/GYN •Family Med Clinic •Psychiatry •Surgery •Practice Mgmt •Electives 4. Other Countries •Japan—6 year program
4 months 4 months 4 months 1-2x/wk 1 month 2 months 3 months 9 months
•Hong Kong—4 years •China—1 year •Singapore—3 years •Australia—3 years •New Zealand—1 year •Sri Lanka—1 year
C. Status of Family Medicine in Indonesia 1. Family Medicine is not yet a specialty for which there is residency training in Indonesia. 2. There is support from the current Menteri Kesehatan to promote Family Medicine as a specialty in Indonesia. 3. Most primary care physicians in Indonesia are General Practitioners without residency training.
4. Pelayanan Kedokteran Keluarga dan JPKM (2004)-- Oleh Depkes, IDI & FKUI •A. “Dokter keluarga harus mempunyai kompetensi khusus yang lebih dari pada seorang lulusan fakultas kedokteran pada umumnya. Kompetensi khusus inilah yang perlu dilatihkan melalui program perlatihan ini.” • b. “Pelayanan diselenggarakan secara komprehensif, kontinu, integratif, holistik, koordinatif, dengan mengutamakan pencegahan, menimbang peran keluarga dan lingkungan serta pekerjaannya. Pelayanan diberikan kepada semua pasien tanpa memandang jenis kelamin, usia ataupun jenis penyakitnya.” c. Sistem Pelayanan Dokter Keluarga “Kontak pertama pasien dengan dokter akan terjadi di Klinik Dokter Keluarga (KDK) yang selanjutnya akan menentukan dan mengkoordinasikan keperluan pelayanan sekunder jika dipandang perlu sesuai dengan SOP standar yang disepakati.” d. Sistem pembiayaan dan menjaga mutu pelayanan dokter keluarga “Beberapa bentuk pembiayaan pemeliharaan kesehatan (tunai-langsung atau fee for service, asuransi ganti-rugi, asuransi dengan taguhan provider, pelayayan kesehatan terkendali (managed care).” 5. Program Magister Kedokteran Keluarga (Program Pascasarjana) •A. Fakultas Kedokteran Universitas Sebelas Maret •Diselenggarakan berdasarkan SK Dirjen Kikti Departmen Pendidikan dan Kebudayaan, 1999 b. Beban Kredit & Jangka Waktu Studi •Sejumlah 50 SKS
•Lama pendidikan 24 bulan (4 semester) •Semester 1-3 pendidikan dalam kampus •Semester 4 untuk penelitian dan penulisan tesis •Kuliah: Jum’at dan Sabtu
c. Tenaga Pengajar •Sp. Ki., Sp. S •M.Sc. M.Sc •Sp. Rad •MS •Sp. Ki. J •Sp. KJ 11
•Sp. A •M. MARS
d. Kekurangan Program FK-USM •Tidak ada pelajaran dalam klinik atau rumah sakit D. Future of Family Medicine in Indonesia •Hopefully –1.Fam Med residency programs will be started –2. Specialty becomes recognized –3. More and more Dokter Umum2 become Family Medicine Specialists. –4. Residency positions should be based on societal and educational needs and not on the ability of medical graduates to pay for residency training. –5. Reform of the specialty training system is needed in Indonesia to meet the need for well-trained generalists. –6. A deficiency of government subsidy for primary care residency training exists. A solution to this deficiency is not readily apparent. This is a task that deserves the advocacy of the Indonesian public and physicians so that a solution can be found. References: Rakel, R.E., Textbook of Family Practice, 6th ed., 2002, W.B. Saunders Company, Ch. 1, pp. 3-18. Boelen, C., et al., Improving Health Systems: The Contribution of Family Medicine, World Organization of Family Doctors and the World Health Organization, 2002. Wonca Workshop Proceedings, Family Medicine Education In The Asia Pacific Region: Core Curriculum For Residency/Vocational Training And Core Content For Specialty Qualifying Examination, 1993. Pelayanan Kedokteran Keluarga dan JPKM, Oleh Depkes, IDI & FK-UI, Depkes Website, 2004. Web sites of interest: www.aafp.org -- American Academy of Family Practice www.globalfamilydoctor.com -- World Organization of Family Doctors www.who.int/ --World Health Organization www.who.int/country/idn/ --World Health Organization, Indonesia www.depkes.go.id/ --Departemen Kesehatan Indonesia