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INTRODUCTION TO FCM AND THE FIVE-STAR DOCTOR

FAM. & COMM. MEDICINE (1ST Shifting) | (Dr. Rouema B. Peralta-Perez) | (9 August 2018)

OUTLINE 5. It assumes continuing responsibility for individual patient


I. Family and Community Medicine follow-up and community health problems.
A. Family Medicine 6. It is a highly personalized type of care.
B. Community Medicine B. COMMUNITY MEDICINE
II. Comparison of Field of Action or Scope of Practice
III. Guiding Principles in FCM • Discipline concerned with the health needs and conditions of a
IV. Core Values of the Profession population using appropriate methods and interventions using
A. Core Values the primary health care approach
B. Characteristics of Approaches to Care • Dealing problems by population groups
V. The Five Star Doctor Roles → Making health plans to address the health needs and to
A. Health Care Provider improve the health status of the people
B. Manager/Administrator • Focuses on the health of a community as a whole rather than on
C. Community Leader/Social Mobilizer individual health (unlike family medicine which is more patient-
D. Researcher/Lifelong Learner centered)
E. Communicator/Educator • Community does not necessarily mean those that live in the same
VI. References place; may also refer to those groups of people having the same
VII. Appendix characteristics (e.g. medical students)
• Promotion of health, prevention of disease and disability,
OBJECTIVES
rehabilitation through collective social action
❖ Define FCM and other associated terms
• In the community, they do continual surveillance wherein follow-
❖ Discuss the scope and principles involved in FCM
ups are done to determine the efficacy of intervention
I. FAMILY AND COMMUNITY MEDICINE
II. COMPARISON OF FIELD OF ACTION OR SCOPE OF PRACTICE
• Twin Forces in Primary Health Care
Table 1. Comparison of Field of Action or Scope of Practice
A. FAMILY MEDICINE
Community Medicine Family Medicine
• Discipline that deals with care for individuals & families in the Other Name Public Health General Practice, More
context of the family involved in a bigger system of General Medicine
(individual→family→community→society→nation) Patient Community Patient and Family
• Academic discipline which includes comprehensive health care Setting Community • Mostly community-
services and research based clinics
→ Integrates the biomedical, behavioral and social sciences • May include hospital-
→ Comprehensive: whole person; “from womb to tomb” based care and
• Medical discipline with a distinct core knowledge and home-based care
characteristic of care, which refers to individuals, family and (hospice)
community and functions within economic, cultural, and social • Workplaces, school
environment and resources (WONCA) and community
• In family medicine, care is provided by individual practitioners →Integration of the
Family Practice concepts of
Occupational Health
• Care that is primary, continuing, comprehensive, preventive,
Approach to *Biopsychosocial; *Biopsychosocial;
curative, referring to individuals, their family and community
Care Health Promotion, Coordinate with
relationship.
Disease Prevention, Referrals (coordinating
• Encompasses ambulatory care, home care, and appropriate care Rehabilitation, care), Examination of
• Putting into action Surveys, Community- the Patient, Diagnosis
Primary Care wide Sampling, Health of Problem, History
• Provision of continuing, comprehensive care to a population Problems (Family)
undifferentiated by age, gender, disease, or organ system (prioritization)
“What would benefit
• Health care that is accessible, comprehensive, coordinated, and
the majority?”
continuing
Activities: Activities:
• It encompasses the following functions (Rakel & Rakel, 2016):
1. It is first-contact care, serving as a point of entry for the • Promote health of • Coordinate among
patient into the health care system. the community the health providers
2. It includes continuity by virtue of caring for patients in • Prevent disease • Linking the
sickness and in health over some period. • Treat and care for community to
3. It is comprehensive care, drawing from all the traditional the sick academic medical
major disciplines for its functional content. • Contribute towards centers, village
4. It serves a coordinative function for all the health care the rehabilitation of health workers,
needs of the patient. disabled people in specialists, and their
the community patients to a wide

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array of resources Activities/ • Variety of • Evidence-based care
Focus: Health of the Focus: Patient-centered Modalities of educational, • Pharmacotherapeutics
community as a care in a Intervention preventive or • Supportive/non-
whole, interventions comprehensive and other pharmacologic
at the individual and continuous manner to interventions • Health education/
group levels all patients within the such as school Counseling
community health • Working with a team
Table 2. Comparison of Field of Action or Scope of Practice (cont.) programs, Referral and networking
Community Medicine Family Medicine immunization
Assessment: Assessment: clinics and
• Entire community or Examination of the nursing homes
subgroups; analysis of patient and diagnosis of for the elderly
indicators, surveys, the patient’s problems; • Community
and community-wide organizing
health assessment and
sampling • Common
Types of health problems
maintenance of an
individual development
and their distribution in
the community • Trans- and
Treatment: Based on Treatment: According to intersectoral
community health diagnosis, preferences, collaboration
problems, priorities, and resources of *Biopsychosocial approach: consideres biological, psychological,
and resources. patients. Intervention: and social factors and their complex interactions in understanding
Intervention: May Usually follows patient- health, illlness and health care delivery
follow data analysis initiated resources
and identification of
trends as recognized
by the community;
more likely to succeed
with community
Figure 1. Views of a Family Physician vs a Community Physician
participation
Continued Continued surveillance: Family Physician→ Individual→ Family→ Community
surveillance: Follow-up to determine
• Family Physician: someone who is able to see the patient in the
Follow-up actions and the need for continued
context of the family, community and society
programs investigation or
→ Sees the individual patients in the context of the family and
treatment
the community, and relate how health problems of the
Quality of Population Clinical perspective
community or population affect families and individuals
Care perspective focuses focuses on how care
→ Targets an individual (i.e. give appropriate care); looks into the
on how health provided by individual or
community where the individual resides since it may have an
systems affect the groups of practitioners
effect on the patient’s condition
health of populations affect the health of their
and reduce disparities patients: adequacy of Community Physician→Community→Family→Individual
in health across resources, delivery of
• Community Physician: addresses the community and the
population groups services, clinical
people’s issues while at the same time, is able to see the situation
performance, and health
in the context of the family and the individual
outcomes
Role of Five-Star Community Five-Star Physician
III. GUIDING PRINCIPLES IN FCM
Doctor Medicine Practitioner Healthcare Provider,
Clinician, Community Social Mobilizer, Table 2. Comparison of Field of Action or Scope of Practice
Development Communicator/Educator, Community Medicine Family Medicine
Advocate, Program Manager/Administrator,
Issues • Community • Family
Manager, Health Unit Researcher, Counselor
empowerment empowerment
Manager, Researcher
• Health in the hands • Domestic violence
(Operations/Clinical)
of the people • *Impact of illness
Goals of • Empowerment • Health promotion and
• Health policy, • Caregivers
Intervention • Maximal wellness
globalization and
participation in • Disease prevention
gender *e.g. Change of roles
decision-making • Cost-effective and development when the breadwinner
• Maximal use of quality care
of the family gets sick
health resources • Shared care with → affects the family as
• Available family enablement a whole if unable to
• Advocacy • Patient and family cope, the family can
empowerment for become dysfunctional
health Orientation • Primary health care • Patient-centered,
approach family focused,
• Community community approach
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development • Biopsychosocial able take into account the situation (i.e. financial/material) of
• Ecologic model approach the patient
→ Only request tests or prescribe medications for the particular
Analysis of Social Determinants of • Family Dynamics disease/problem
Health Health and Disease • Social, Cultural, • Primary
Situation Religious, Economic, → Preventive rather than curative
Environmental, • Person-centered
Educational, Medical • Promotes health and well-being
Tools • Statistics, • Genogram, APGAR, • Participatory
Epidemiology Ecomap, SCREEM → Two-way
• Participatory • Family Assessment ▪ Should not be messianic, patients must also participate but
Research Tools we cannot force them (patient’s autonomy)
Methods • Community-based • ▪ Patient as a member of the family and community
Health Programs ▪ There should be an agreement between a doctor and the
• Community patient regarding the treatment that will be given
Organizing Process
• Health Promotion V. THE FIVE STAR DOCTOR
• Local Health A. CONCEPT
Manpower
Development • The five-star roles, coined by WHO-DOH in the 1990’s, is
• Control of proposed as the ideal profile of a doctor possessing a mix of
Communicable and aptitudes to carry out the range of services that health care
Non-communicable settings must deliver to meet the requirements of relevance,
Diseases quality, cost-effectiveness and equity in health.
• Adopted by the Philippine medical schools & CHED
IV. CORE VALUES OF THE PROFESSION • Used as the professional roles which medical graduates will
perform when they start their work as practitioners
A. CORE VALUES B. DEFINITION OF TERMS
• Integrity, Ethical Behavior • Relevance
• Compassion, Nationalism → The degree to which most important community-
→ Compassion: attempt to feel along with the patient perceived problems are tackled
→ Nationalism: serving the country and upholding the Filipino → Upgrading health status by addressing priority problems as
core values wherever we are serving can be identified through community surveys
→ Empathy vs Sympathy → Problems must be prioritized with basis
▪ Empathy: ability to share someone else’s experience ▪ What to address first when attending a patient?
▪ Sympathy: being inclined to think and feel similarly • Quality
• Holistic (Systems approach) → Use of evidence-based data and appropriate technology to
→ Concerned with complete systems rather than individual parts deliver comprehensive health care to individuals and
• Commitment to lifelong learning populations, taking into account their social, cultural and
• Resourcefulness consumer expectations
→ Capable of devising new means to solve problems → Should produce the desired effect without putting the
• Competence patient in harm’s way
→ Level of competence should be parallel to the level of ▪ Evidence-based data
confidence − Information regarding effectiveness and safety
• Sensitive to health needs of the people based on research, clinical trials, scientific studies
• Gender sensitivity and/or journals
→ Sensitive to the needs of a female patient and a male patient ▪ Appropriate technology
(e.g. patients living with HIV) − Method, technique, equipment or drug that are
B. CHARACTERISTICS OF APPROACHES TO CARE simple, accepted by the community (based on
norms, tradition, culture, socioeconomic status)
• Continuing and should address the pressing needs of the
→ Ongoing responsibility for managing a patient’s medical care in patient (consumers)
which follow-up is a must − Should be used by local health workers under local
• Comprehensive conditions
→ From primary health care to tertiary health care; spans the ▪ Consumer expectations
entire spectrum of medicine − To be cured with affordable, accessible, and quality
• Cost-effective health service
→ Use of evidence-based date and appropriate technology while • Cost-effectiveness
utilizing resources available in the community → Those that have the greatest positive impact on the health
→ Physician who is well acquainted with a patient provides more of a society while making the best use of its resources
personal and human medical care and more economically → Produce desired effect with the least cost to the
sound than a physician involved in only episodic care-will be community
→ Use available resources, both in medication & manpower

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▪ Indigenous resources, herbal medicines, traditional Skills as a Manager/Administrator
methods
→ Should be able to prescribe drugs or request diagnostic • Referral system
exams for patients which will directly help in treating the • Community organizing and management
disease as compared with wasteful prescriptions which • Home care and (includes home visits if needed)
also target symptoms absent in the patient • Health risks and environmental issues (e.g. company or school
• Equity physician)
→ Striving towards making high-quality health care available • Health policies and legislation
to all C. COMMUNITY LEADER/SOCIAL MOBILIZER
→ People’s needs, rather than social privileges, guide the
• Does not simply treat individuals who seek help but will also
distribution of opportunities for well-being
take a positive interest in community health activities that
▪ Distribute health services by giving more to those who
will benefit large numbers of people.
need more (based on socioeconomic status)
• Who, after having won the trust of the people among whom
V. THE FIVE STAR DOCTOR ROLES he or she works with, can reconcile individual & community
requirements and initiate action in behalf of the community.
A. HEALTH CARE PROVIDER • The core of primary health care is people empowerment
• Caring function of physicians emphasize our personalized • A physician has the task to change specific behavior of
approach (compassion – sympathy, empathy) to health care patients & their families or members of the community to
and our commitment to understand the patient as a person. achieve a goal.
• Considers patient as integral part of the family and • A physician plays a catalyst role in accelerating & sustaining
community, and takes into account the total needs of the program implementation through active and collective
patient (physical, mental, social, and emotional). participation of GOs and NGOs in the community.
→ Not just viewed as a case • Involve the community in the identification of the problem,
• Priority is to help others even when one’s life is in danger planning of the program, and in the implementation.
• Provides healthcare to everyone—be it people from opposite • Teach the community how to identify and solve the problem.
perspectives, people with no money to pay for the medical → Advocates for “people empowerment”, helping the people
expenses, etc. realize their potential in resolving their own problems
• Ensures health care is of highest quality given the limited D. RESEARCHER/LIFELONG LEARNER
resources and facilities
• Ensures that a full range of treatment (curative, preventive or • Research is important in the delivery of health care services
rehabilitative) will be dispensed in ways that are even in the primary care level
complimentary, integrated and continuous → Because medicine is dynamic
• Able to cultivate a good doctor-patient relationship • Chooses which technology to apply ethically & cost effectively
considering various ethical principles while enhancing the care that he or she provides.
→ Establish trust and rapport • Uses evidence‐based medicine in the practice of the
• Able to cultivate good relationship with colleagues and allied profession.
professionals in order to give the best care to patients • Has the responsibility to add to the body of knowledge so
→ Know your limits as a doctor, and know when to refer that more effective training can be offered to future
practitioners even at the undergraduate level
Skills as a Healthcare Provider • Able to critically appraise literature to be able to make good
• Communication skills decisions in terms of treatment and management.
• History taking → In order to deal with the changes of generation of your
• Physical examination patients, embrace literature material.
• Clinical and diagnostic reasoning • Be able to keep medical records which will serve as future
• Prescription writing references
• Doctor-patient relationships • Employs participatory researches, equipping the community
• Assessing families (health status and risks) with the appropriate knowledge and skills while learning from
• Preparing health care plan and health promotion them, to be able to complete a research based on the
community’s needs
B. MANAGER/ADMINISTRATOR
E. COMMUNICATOR/EDUCATOR
• Manages a clinic, hospital, community health programs (long-
term & projects (short-term) • Doctors of tomorrow must be excellent communicators in
• Can work harmoniously with individuals & organization, order to persuade individuals, families, and the communities in
within & outside the health care system, in order to meet his their change to adopt healthy lifestyles and become partners
or her patient’s & community needs in the health effort
• Coordinate health care of patients & their families with other → Ultimate goal of health education: change in behavior
physicians & agencies through referral, networking & linkages • Able to promote healthy lifestyle by empathic explanation,
→ It is the doctor’s responsibility to coordinate and refer to empowering individuals, and groups to enhance and protect
other agencies or municipalities when the help is needed their health
• Chooses the most appropriate action for a given health → Live by example
condition in a given situation Skills as a Communicator/Educator
• Responsible as the leader of the health team
• Establish rapport with people as well as good doctor-patient
→ Makes sure that all the projects and programs are relationship
implemented
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→ Use a welcoming expression, greet patient with modulated − do not introduce new material
voice ▪ Non-directive
→ Proper eye contact, posture, show interest and avoid ▪ e.g. “Tell me what bothered you when you saw his
mannerisms dead face?”
• Assess the patient’s belief and perception about the illness ▪ Guidelines in making a judgment call as to where to
→ Adapt health belief model lead the counseling session:
• Actively involve the patient and the family in the decision- − Note wherever the feeling is greatest or most
making process intense
→ It is up to the compliance of the patient to the doctor’s − Pay attention to what the patient has set aside to
health regimen, or his/her capability to comply whether be mentioned last, as oftentimes, he will mention
he/she will be cured many things, but only as a prelude to the more
→ Thus, it is important to include the patient in the decision- important issues which he saves for last
making process of his/her treatment • Reflecting Skills
→ Family: main support system and would → The patient who is emotionally burdened is unable to see
positively/negatively affect patient compliance himself or his situation clearly
• Use language understood by the patient and his family → The role of doctor-counselor is to act as a minor so that
→ Avoid using medical jargons the patient can see himself and his situation more clearly
→ Use Layman’s terms or local terms → Takes the verbal content of what the patient says by
• Facilitate learning through a variety of methods paraphrasing it so as to make it clearer
→ Increase in learning and values
Clinical Scenario
• Enlist the reinforcement of social support
• Evaluate change and give feedback 45/M walks in the office, sits down, then stands up again and looks
out the door to where his wife is sitting. He shuts the door and sits
Active Listening Skills down again.

• Attending “Doctor, a month ago, I had this sore throat, so I went to a doctor
→ “Attention” and “paying attention” and he gave me penicillin for it. So, I took for 7 days and it went
→ Paying attention to the needs of our patients to be away. But a week later, I had the sore throat again.”
understood and cared for emotionally
→ Refers to the way we use our bodies to communicate the “The doctor gave me Amoxicillin this time and took it and the sore
message throat went away. But a few days ago…” (Patient takes his
→ Attending skills handkerchief and crumples it and pulls at it repeatedly.)
▪ L – leaning forward
▪ O – open stance “…the sore throat came back.” (Voice becomes softer, patient
▪ V – voice of compassion shakes his head)
▪ E – eye contact
▪ R – relaxed position “I just can understand what is happening.”
▪ S – sitting at an angle
• Reflecting Content
• Bracketing → Paraphrasing
→ Setting aside our own feelings, thoughts, and judgments ▪ Gets the essential content of the patient’s message
temporarily so that there will be space in our minds and in and restates it in a more summarized and organized
our hearts for what the patient is really saying manner
• Leading ▪ e.g. “This is the third time that you have had a sore
→ Indirect Leading throat within a month and you can’t understand why it
▪ Open invitations made by the doctor-counselor for the keeps coming back.”
patient to talk about anything that s/he wishes → Perception Check
▪ Allows the patient to go wherever topic he chooses ▪ In interrogative form, reorients the doctor if he was
and the doctor-counselor encourages him to do so mistaken, gives the patient the chance to re-explain
− ✓ “What would you like to talk about?” himself in a clearer manner
▪ e.g. “This is the third time you have had a sore throat
− ✓ “What can I do for you?”
within a month and you can’t understand why it keeps
− ✗ “What is your problem?” (too direct and may be
coming back, is that it?”
threatening)
• Can also take the form of words of phrases like: • Reflecting Feeling
− “Yes” → The doctor-counselor articulates the feelings of the patient
− “Go on” by making an observation
− “And then?” → e.g. “You seem to be quite anxious about your sore throat.”
− “Uh-hmm” • Reflecting Experience
→ Direct Leading → Reflecting the non-verbal cues to the patient
▪ The doctor-counselor makes a judgment call as to → e.g. “I noticed that your lips quivered when I talked about
where the patient should go and asks the patient to go blood.”
to that direction
• Focusing
▪ Pick up from what the patient has already brought out
→ The doctor-counselor stirs the conversation into the topic
into the open.
that is relevant to the patient’s concern

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→ “This point seems worth looking at more closely.”
→ “You said something earlier that I want you to go back to.”
→ “You have financial difficulties, your wife is nagging you,
your daughter is rebellious, and your son had been on an
accident. That is quite a lot. But of these four, which is the
one that gives you the most pressure?”
• Probing
→ The doctor-counselor asks the question that can elicit
more information from the patient.
→ Questions to be asked must be open-ended and not
answerable by a yes or no
→ “How? Could you explain?”
→ “Could you tell me more?”
→ “Could you give an example of…?”
→ “How does that make you feel?”
→ “Can you tell me more about the feeling?

V. REFERENCES
Dr. Peraltas’s PPT and Lecture Notes (10 August 2017)
Batch 2021-B Transcription
Batch 2021-D Transcription
Rakel, R and Rakel D. (2016). Textbook of Family Medicine, 9th
Edition. USA: Elsevier.

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