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 FAMILY MEDICINE
A Clinical and Applied Orientation

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 FAMILY MEDICINE
A Clinical and Applied Orientation

Second Edition

CS Madgaonkar MBBS FCGP

Consultant Family Physician
Hubballi, Karnataka, India
Honorary National Professor
Indian Medical Association
College of General Practitioners
Chennai (HQ), Tamil Nadu, India

Forewords
RP Pai
RN Joshi
KH Jituri
GN Prabhakara

The Health Sciences Publisher

New Delhi | London | Philadelphia | Panama

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 Jaypee Brothers Medical Publishers (P) Ltd

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© 2015, Jaypee Brothers Medical Publishers

The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent
those of editor(s) of the book.

All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical,
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All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their
respective owners. The publisher is not associated with any product or vendor mentioned in this book.

Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject
matter in question. However, readers are advised to check the most current information available on procedures included and check
information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of
administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions.
Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or
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This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or
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Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

Family Medicine: A Clinical and Applied Orientation

First Edition: 2006
Second Edition:  2015
ISBN 978-93-5152-911-8
Printed at

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 Dedicated to
The memory of
My loving parents

Smt Sumitra S Madgaonkar

Shri Sachidanand G Madgaonkar

There is no death! The stars go down

To rise upon some other shore,
And bright in Heaven’s jeweled crown,
They shine for ever more.
—John L McGreey

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 Foreword

I have great pleasure in offering this testimonial. Dr CS Madgaonkar has done great job in
writing the book entitled Family Medicine: A Clinical and Applied Orientation. Though Dr
CS Madgaonkar is not a full-time teacher in a medical college, he has excelled like a formal
pedagogue. In the days of consumer-oriented, globalized, e-focused medical practice, this book
is a value edition to the desk of a primary care physician.
Most informative and educative, this book focuses on current issues. I particularly liked
the chapters ‘The Difficult Patient’ (Chapter 22), ‘Medical Professionalism’ (Chapter 23) and
‘Comprehensive Geriatric Assessment’ (Chapter 27). This book is a must for all, Primary Care
Physicians, Departments of Community Medicine and Forensic Medicine.
In the days of recertification and accreditation, this book is a worth investment. I recommend
this book without any hesitation to medical students for their internship.
God bless Dr CS Madgaonkar and M/s Jaypee Brothers Medical Publishers for publishing
this ready reckoner.

Salubriously,
RP Pai MS MD PhD
Visiting Professor, School of Public Health, Austria
Professor
Department of Public Health and Primary Care
The International Centre for Health Sciences
Manipal Academy of Higher Education
Manipal, Karnataka, India

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 Foreword

Dr CS Madgaonkar MBBS FCGP, Consultant Family Physician is a sincere dedicated doctor

devoted to the welfare of his patients. Despite being a busy professional Consultant Family
Physician, he has taken a lot of time off in preparing his book on family medicine, which is an
eye-opener for all family physicians. I had said many times in our medical colleges, and Dr CS
Madgaonkar, I say with all my force, that he should occupy the first chair in that department.
There is a tendency among doctors to specialize; our country still consisting of 60% rural
population, cannot afford the costly treatment of specialists. At the base of the pyramid should
be the family physicians, and at the apex be the specialists. Base should be wide to aid the basic
and routine treatment to the daily masses. But we see, unfortunately, the reverse of the pyramid
that the base is getting smaller and the apex formed by specialists, is getting wider which is not
conducive to the health of our developing nation like India; hence, doctors like CS Madgaonkar,
would train younger doctors in family medicine if he occupies the professional chair of family
medicine and train them, most of the younger doctors would take to family medicine.
It is truly said if one does not know computers, particularly in the field of medicine, one is
considered as ignorant and no patient would like to take treatment from ignorant doctors.
May the creed of Dr CS Madgaonkar rapidly multiply and may his knowledge of family
medicine be utilized by the universities.
Let us emancipate the students and give him time and opportunity for the cultivation of
his mind, so that in his pupilage, he shall not be a puppet in the hands of teachers, parents
and society but rather a self-relying, and reflecting being. After all, we are still students in the
advancing science of medical knowledge and Dr CS Madgaonkar has proved his book is a treat
in family medicine and knowledge of computer is superb.
I wish him all the best.

RN Joshi
MBBS FRCS FICS FIAMS FIMSA
Consultant Surgeon
Dr Joshi Hospital
Hubballi, Karnataka, India

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 Foreword

I have read the book Family Medicine: A Clinical and Applied Orientation by Dr CS Madgaonkar,
a renowned family physician practicing for the last three decades. I recommend this book to
all those who desire to practice the art of family medicine. It contains useful hints, which are
essential for successful practice in this subspecialty.
The author has written this book in a simple fluent language and in an academic style, in
spite of his busy schedule. He deserves compliments for his unique attempt in giving out his
experience to the beginners.

KH Jituri MD FIAMS FICC

KH Jituri Hospital
Hubballi, Karnataka, India

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 Foreword

Family Medicine: A Clinical and Applied Orientation by Dr CS Madgaonkar from Hubballi,

Karnataka, is a good attempt for the depiction of family medicine in terms of basic principles,
content, practice, prevention in family medicine and research in family medicine.
Indeed, a teacher for the past 37 years I could see the depth of knowledge of the author in
the field.
He has kept the syllabus of certain training in family medicine including DNB conducted
by National Board of Examination.
I wish the author success and I wish the Publisher the success.

GN Prabhakara
MBBS MD MAMS MAPHA MIPHA
Associate Dean, Professor and Head
Department of Community Medicine
Professor and Head
SDM College of Medical Sciences
Dharwad, Karnataka, India

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 Preface to the Second Edition

The second edition of this textbook, Family Medicine: A Clinical and Applied Orientation has
been entirely updated and much of it has been revised. Since nine years of its first publication,
the discipline of family medicine has been greatly developed and refined so that the faculty
of family medicine and general practice are at the forefront of medical education. In an
increasingly global environment for the need of more primary care physicians, and to create
a robust primary care system that is vital to the sustainability of nation’s health care system,
the apex medical councils, especially in developing countries, are in favor of implementing in
near future strategies to ensure proper place for family doctors in healthcare delivery systems
by establishing new departments of family medicine in all medical colleges at undergraduate
and postgraduate levels. Addressing the changes in the medical curriculum, Family Medicine:
A Clinical and Applied Orientation covers the theoretical background of family medicine and
provides essential skills needed to practice in the changing paradigm shift from secondary and
tertiary care to the primary care.
In the present times, with the full spectrum of challenges, modern medicine is expected to
address, family medicine offers flexibility and tremendous diversity. The contemporary family
physicians have at their disposal broad base of literature and skills. The opportunities that family
practice affords in terms of academic and community healthcare delivery, together with great
organizational advancements that have occurred in family medicine and general practice, offer
rich learning resources for budding family physicians. In this context, the present edition is
updated and designed to cover a wide field of common clinical and bedside problems, especially
encountered in the application of its art and science of family medicine. It is hoped that this
treatise for practicing family physicians will encourage deep learning and attempt to reflect its
core information in the clinical and applied aspects, and make them more competent in the
care of their patients. It is hoped that this book will continue to gain appreciation and maintain
its importance. I welcome healthy suggestions and constructive criticism from readers through
email to me (Vidya_csm@yahoo.com) or via my website www.doctorcsm.in or the publishers.

CS Madgaonkar

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 Preface to the First Edition

“Before everything else, getting ready is the secret of success.”

—Henry Ford
“All things are ready if our minds be so,” said Shakespeare.
Now that you have made up your mind to invest in this book, is this investment going to help
you be a successful doctor?
Is success elusive or tangible? More so, in medical practice, is success elusive or tangible?
It is generally said that joy, which is internal to one is tangible and the success, which is an
external measure, is rather elusive.
Look at it this way—at the end of each day, you can actually count the number of joyous
episodes you experienced, spread over, familial episodes, patient-related episodes and so on.
But, you will never be too sure of successes that you may achieve during the course of the day!
This book is about increasing both the tangible joy that you experience as a Doctor and the
success that you hope to achieve as a Physician. In a way it is like excellence and perfection.
Perfection may be an illusion, but the process toward it is not. Granted that success may appear
elusive, but the process toward that elusive end is not. This book is about those processes.
Although this book is for Doctors, it is also intended for anyone interested in the domain of
medicine. It is not just about medical practice that one usually learns in medical college. This
book is about successful medical practice, something that was not taught to you, but perhaps
learnt along the way.
I believe this book would have served its purpose, if you were able to pick up some points
from the book and enhance your success in medical practice.
“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which
your heart will be exercised equally with your head”, said Sir William Oslar.
So, let me sign off by encouraging you to write to me if you have found interesting or unique
success formulae for yourself by using your heart and head equally.

CS Madgaonkar

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 Acknowledgments

Any accomplishment requires the efforts of many people and this work is no different.
I wish to express my heartfelt gratitude to those who have used this manual. I have received
positive feedback from medical students as well as from many GPs, especially those who were
preparing for fellowship examinations in family medicine, who found the first edition to be a
quick, practical reference text.
I wish to gratefully acknowledge the help, advise of the following who reviewed this book:
Dr RM Pai, Professor of Public Health and Primary Care, Mangaluru; Dr RN Joshi, Consultant
Surgeon, Hubballi; Dr KH Jituri, Consultant Physician, Hubballi; Dr Prabhakara, Emeritus
Professor and Head, Department of Community Medicine, SDM College of Medical Sciences,
Dharwad; and Mr Narayan B Gad, Past Chief Executive of Formulations Marketing for Panacea
Biotec Ltd. Their comments and criticisms helped shape a better product.
My special thanks to my wife, Dr Vidya for her critical and timely review of the manuscript.
She has read and revised majority of the chapters and has offered invaluable advice.
I am grateful to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President) and
Mr Tarun Duneja (Director–Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd,
New Delhi and their editorial staff for the invitation to produce the second edition of the Family
Medicine: A Clinical and Applied Orientation.
I would like to thank my loved family members for their most generous assistance.
Last but far from least, I am indebted to my wife, Dr Vidya, and our son Varun, for their
unstinted support and constant encouragement throughout the entire process—from conception
to completion of this book.

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 Contents

SECTION 1: BASIC PRINCIPLES

1. Philosophy of Family Medicine 3
2. Scope of Family Medicine 8
• Three Facets of Family Practice  8
• Matrix of Family Practice  9
• Proactive Role of Family Physician  10
3. Family Medicine—The Rising Discipline 12
• History 12
• Age of Specialization  14
• Revival of Family Medicine  15
• Future 17
• Family Medicine—Need of the Hour  20
4. Definitions 22
• General Practice  22
• Leeuwenhorst Definition  22
• Changing Domain of General Practice  22
• Wonca Definition—1991 (World Organization of Family Doctors)  24
• Olesen Definition—2000 24
• The European Definitions—2005 (WONCA Europe Definitions—2005)  25
• Definition of General Practitioner  29
• Definition of Family Physician  30
• Family Practice  31
• Difference—Family Practice and General Practice  31
• Advantages of Family Practice  31
• Primary Care  32
5. The “Family” in Family Medicine 37
• Focus on Family Health Care  37
• Family—Definition 37
• Characteristics of a Healthy Family  38
• Characteristics of a Disturbed Family  39
• The Family Life Cycle and Role of Family Physician  39
• Family Dynamics and Illness  41
• Family in Crisis  43
• Family-based Medical Counseling —The “Bathe” Technique  46
• Working with Families—Avoiding Pitfalls  47

SECTION 2: HEALTH FOR ALL

6. The Alma-Ata Declaration 51
• Background 51
• The Genesis of Alma-Ata  52
• Primary Health Care Takes Center Stage  52
• Declaration of Alma-Ata  152

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 xxii  Family Medicine: A Clinical and Applied Orientation
7. Primary Health Care Approach to Health for All 55
• What is “Health for All”?  55
• HFA—The Fundamental Principle  55
• The Genesis of Primary Health Care  56
• The Concept of PHC  56
• PHC Definition  57
• The PHC Approach  57
• Ingredients of PHC  57
• PHC Revival—Beyound Declaration  59

SECTION 3: CLINICAL APPROACH

8. The Spectrum of Clinical Diagnosis 63
• Clinical Process—History and Symptomatology  64
• Clinical Process—Physical Diagnosis  67
• Sequence in Clinical Diagnosis  68
• Diagnosis in Family Practice  70
• The Differential Diagnosis  72
• Changing Conceptions of Health, Disease and Diagnosis  72
9. Investigations: General Principles 76
• Refining Clinical Diagnosis  76
• The Reason for the Test  77
• Analytical Errors  77
• Interpretation of Tests  78
• Importance of Chronological Data  81
• Right Choice of Test  81
• Gold Standard Tests  82
• Who the Investigation for: Patient or Doctor?  82

SECTION 4: THE PRACTICE OF FAMILY MEDICINE

10. Communication Skills 87
• Communication as a Core Competency  87
• Definition 88
• Importance of Effective Communication  88
• Key Tasks in Communication with Patients  89
• Key Communication Skills Needed to Perform Key Tasks  89
• Communication Types  91
• Communication with Children  92
• Communication with Older Patients  93
• Barriers in Communication  93
• Common Communication Pitfalls  95
• Acquiring New Skills  95
• Neurolinguistic Programming  95
11. Rapid Access to Improving Communication Skills 97
• Changing Practice Environment  98
• Refining Communication Skills  98
12. The Consultation 104
• Objectives for the Consultation  104
• Tasks in the Consultation  105

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 Contents xxiii
• The Consultation Process  106
• Interviewing Skills  109
• Common Pitfalls when Interviewing Patients  113
• Consultations as Routines, Dramas and Ceremonies  113
• Patient Satisfaction with the Consultation  114
• Troublesome Consultations  114
13. The Physician-Patient Relationship 116
• Concepts and Changes  116
• Types 117
• Scope of Physician-Patient Relationship  118
• Ending the Physician-Patient Relationship  121
14. Balint Group 123
• Historical Origins  124
• Balint Groups  124
• Balint Training  125
• Balint Discoveries  126
15. Designing a Patient-friendly Practice 130
• Objectives to Redesign  130
• Designing the Clinic  131
• The Waiting Room and Reception  131
• The Consultation Room  132
• Staff 133
• Greeting Patients—Checking-in and Checking-out  133
• Incorporating New Technology  134
16. Counseling Skills 136
• Counseling Interventions in Primary Care  136
• Counseling 136
• Specific Areas of Counseling  138
• Counseling Procedure  139
• Counseling Strategies  140
17. Patient-centered Care 143
• Why Such Broad Use?  144
• Defining Patient-centered Care  145
• Evidence Base for Patient-centered Care (PCC)  147
• Patient’s Choice  147
• Patient-centeredness—What Determines the Physician’s Clinical Behavior?  148
• Patient-center Care Model  148
• Hypothetical Case Scenario: An Adult Diabetic  149
18. The Team Approach 153
• Need for Team Concept  153
• Personal versus Team Care  154
• Team Training: Current Status and Assessment  154
• Working with Colleagues  155
• Communication Strategies  156
• Team Cover on Off-Duty or Leave  157
19. Leadership 159
• Physicians as Leaders  159
• Changing Leadership Competency  160
• Physicians as Better Leaders  160
• Developing Physician Leaders  161

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 xxiv  Family Medicine: A Clinical and Applied Orientation
• Characteristics of Leadership  162
• Tools for Leadership  163
• What Physicians should do when Asked to Lead?  164
20. Addressing Medical Errors 168
• New Approach—Acknowledge Mistakes  169
• Medical Errors—Focus on Primary Care  169
• Definition 169
• Types of Errors  171
• Classification 171
• Understanding Errors in Family Practice  172
• Why should Doctors Disclose Medical Errors  173
• Why Doctors do not Disclose Errors  174
• System Redesign in Family Practice  175
• Apology as a System of Medical Error Disclosure  176
• Eliminating Errors in Family Practice—Current Trends  177
• How to Cope with Clinical Errors  180
• What Patients can Do  180
21. Medical Records 184
• Purpose of Record Keeping  184
• Standards in Medical Record-keeping  185
• Content and Style  185
• Practical Ways of Improving Record-keeping  186
• Weed System: Problem-oriented Medical Record (POMR) and SOAP 186
• From SOAP to “SNOCAMP” 190
• Medical Council of India (MCI)—Importance of Medical Records  191
• Medicolegal Records  192
22. The Difficult Patient 195
• Terminology and Incidence  196
• Characterizing the Difficult Patient  197
• Who is at Fault  198
• Problems in the Physician  199
• Problems in the Physician-Patient Relationship  200
• Disorders to Consider  200
• Strategy to Handle Difficult Patients  201
• Coping Skills for Physicians  202
• Coping Skills for Family Physicians  204
• The CALMER Approach  204
23. Medical Professionalism 208
• Professionalism—Pitfalls 209
• The Evolution of Professionalism  209
• Defining Professionalism  210
• Fundamental Ethical (Moral) Principles­  211
• A Set of Professional Responsibilities  212
• Model Behaviors of Professionalism  214
• Unprofessional Behaviors  215
• Reasons for Teaching Professionalism  215
• The Educational Challenge  215

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 Contents xxv

SECTION 5: ADOLESCENT HEALTH

24. Adolescent Care 221
• Introduction 221
• Definition 222
• Adolescent Consultation  223
• Exploring Hidden Agenda  224
• Confidentiality 224
• History 224
• Adolescent Communication  226
• Communication Techniques  226
• Physical Examination  227
• Counseling 228
• Goals of Counseling  230
• Improving Existing Services—Adolescent Care Clinics (ACC) 230
25. A Problem Adolescent 233
• Parenting Stress  233
• Parenting Style and Problem Adolescent  233
• Behavior Problems  235
• Adolescent Depression  235
• Suicidal Risk  236
• Physician’s Role  237
• Indications for Psychiatric Referral  238
• A Scheme for Fortifying the Parent-Adolescent Relationship  238
• Guidance and Counseling to Parents  239
• Preventive Advice to Parents and Family Members  239

SECTION 6: GERIATRIC HEALTH

26. Aging and Geriatric Concepts 243
• Definition 243
• Demographic Revolution  244
• The Role of Family Physician  244
• Characteristics of Disease in Elderly  245
27. Comprehensive Geriatric Assessment 249
• Barriers to CGA  250
• Medical Assessment  251
• History Taking and its Pitfalls  251
• Important Specific Areas  252
• Physical Examination and its Pitfalls  254
• Investigations 259
• Mental Status Examination  259
• Functional Evaluation  259
• Advance Directive 262
28. Management of Common Geriatric Problems 264
• The “Age Wave”  264
• Paucity of Geriatric Care  265
• Geriatric Care and Family Physician  265
• Atypical Symptoms  266
• Physician’s Role  266

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 xxvi  Family Medicine: A Clinical and Applied Orientation
• Major Manifestations of Common Geriatric Problems  268
• Psychological Problems and Elder Abuse  270
• Cardiovascular Problems  271
• Respiratory Problems  273
• Gastrointestinal Problems  274
• Incontenance and Urogenital Problems  274
• Endocrine Problems  275
• Musculoskeletal Problems  276
• Falls and Balance Problems  277
• Visual Impairment  278
• Hearing Problems  279
• Nutrition 279
• Attitudes for a Successful Geriatric Practice  280
29. Practical Prescribing to the Elderly 283
• Concerns over Aging Population  283
• Prescribing Cascade  284
• Polypharmacy 285
• When should an ADR be Suspected?  286
• Principles of Good Prescribing  287
• Non-drug Therapy  287
• Begin Therapy with Clear Endpoints in Mind  288
• Treat the Disease Process Rather than Symptoms  289
• Start Low Go Slow  289
• Medication Debridement—Reducing Medications and Doses  289
• Review the Drug Profile at Every Visit  289
• Effective Communication  290
• Medication Noncompliance in the Elderly  290
• Measures to Enhance Compliance  290
• Ethical Principles  291

SECTION 7: PALLIATION AND BEREAVEMENT

30. Communicating Bad News 295
• What is Bad News?  295
• Why is Breaking Bad News So Difficult?  295
• Importance of Disclosure  297
• What Patients Value  297
• How Should Bad News be Delivered?  298
• Communication in Specific Situations  300
• The Future  300
31. Palliative Care: Principles 303
• Recognizing Dying  303
• The Need for Palliative Care  303
• Special Role of the Family Physician  304
• What is Palliative Care?  304
• Principles of Palliative Care  306
• Tasks in Palliative Care and Care of the Dying  307
• When Death is Approaching: Diagnosing Dying­  308
• Patient—Family Involvement: Shared Decision Making  308
• Identification and Management of Symptoms  310
• Support of Family and Carers  312

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 Contents xxvii
• Support after the Death  312
• The Limits of Care at the End of Life  313
• Summary of Tasks for the Patients in the Dying Phase  313
• Conspiracy of Silence  313
32. Palliative Home Care 316
• Caring at Home—Some Considerations  316
• Definition 317
• Home Care: Issues in Developing Countries—is There a Need?  317
• Demoralizing Syndrome  319
• Home—The Preferred Choice  319
• Involvement of Family Physician  320
• How to Get Started and Keep Going  321
• Clinical Issues  322
• Patient Issues  323
33. Family and the Grief Process 327
• What is Grief?  327
• Symptoms of Grief  328
• Features of Grief  328
• Course of Grief  329
• Types of Grief Reaction  329
• Risk Factors for Complicated Grief  330
• Family Physician as Counselor  330
• Guidelines to Manage a Grieving Person and Family Members  331
• Referral 331

SECTION 8: PREVENTION AND HEALTH CARE

34. Prevention in Family Practice 335
• The Power of Prevention  335
• Prevention—Family Physician’s Role  336
• Prevention—Limiting Factors  336
• Promoting Prevention  337
• Levels of Preventions and Screening  337
• Opportunity for Prevention  338
• Scope for Prevention  339
35. Preventive Care Delivery: Barriers and Remedies 346
• Overview 346
• Barriers to Prevention  346
• Solutions to Barriers  351

SECTION 9: EDUCATION AND RESEARCH

36. Clinical Audit 359
• Why is Clinical Audit Important?  360
• Different Between Medical and Clinical Audit  360
• Multiprofessional Clinical Audit in Family Practice  361
• Difference Between Clinical Audit and Research  361
• The Audit Cycle  361
• Steps in Clinical Audit in any Particular General Practice  362
• Keep a Record  364

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 xxviii  Family Medicine: A Clinical and Applied Orientation
• Confidentiality 365
• Audit—Pitfalls 365
37. Evidence-based Medicine: Principles 366
• A Case Scenario  366
• Case Study Continued  366
• Learning of Evidence-based Medicine (EBM)  367
• What is Evidence-based Medicine?  367
• Distinguishing Features of EBM 367
• Where did EBM Come From?  368
• The Rationale for EBM—The Paradigm Shift  368
• Definition of EBM and EBP  369
• Steps to Practicing EBM  370
• Advantage of EBM 373
• Limitations of EBM 373
• Misconceptions about EBM  374
38. Evidence-based Medicine: Practice 376
• Evidence-based Practice  376
• Adherence of EBP in General Practice/Family Medicine  376
• Concerns about EBM in Primary Care Practice  377
• Essentials of EBM in Primary Care Practice  380
• The Future of EBM in Primary Care  380
39. Research in Family Medicine 384
• Background of Research in Family Medicine  384
• What Constitutes Family/General Practice Research?  385
• Types of Research Methodology  386
• Good Research in Family Practice  389
• Research Strategies for Family Medicine  390
• Aims and Objectives of Research in Family Medicine  390
• Methodology or Logistics of Research  390
• What can Family Physicians do  391
• Suggested Research Training and its Incentives Rewards  393

Appendices 395
Index 407

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 1
Section

Basic Principles
™™ Philosophy of Family Medicine
™™ Scope of Family Medicine
™™ Family Medicine—The Rising Discipline
™™ Definitions
™™ The “Family” in Family Medicine

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 1 philosophy of
“The art of medicine cannot be inherited, nor can it be copied from books....”
In 1927, in his now-famous essay "The Care of
the Patient," Dr Francis Peabody, a physician,
teacher and humanitarian affirms:
“The practice of medicine in its broadest
sense includes the whole relationship of
the physician with the patient. It is an art,
based to an increasing extent on the medical
sciences, but comprising much that still
remains outside the realm of any science. The
art of medicine and the science of medicine
are not antagonistic but supplementary to
each other… good practice presupposes an
understanding of the sciences that contribute
to the structure of modern medicine, but it
is obvious that sound professional training
should include much broader equipment.
The treatment of disease may be entirely
impersonal; the care of the patient must be
completely personal. The significance of
the intimate personal relationship between
physician and the patient cannot be too
strongly emphasized, for in an extraordinarily
large number of cases both diagnosis and
treatment are directly dependent on it, and
the failure of the young physician to establish
this relationship accounts for much of his
ineffectiveness in the care of patients.
What is spoken of as a “clinical picture” is
not just a photograph of a man sick in bed; it
is an impressionistic painting of the patient
surrounded by his home, his work, his relations,
his friends, his joys, sorrows, hopes and fears.
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Family Medicine
— Paracelsus
Thus, the physician who attempts to take
care of the patient while he neglects those
factors that contribute to the emotional life of
his patient is as unscientific as the investigator
who neglects to control all the conditions
that may affect his experiment. The good
physician knows his patients through, and his
knowledge is bought dearly. Time, sympathy,
and understanding must be lavishly dispensed,
but the reward is to be found in that personal
bond which forms the greatest satisfaction of
the practice of medicine.”
These prolific words of wisdom, embedded
indelibly into the minds of generations of
medical students, concluded the lecture given
by Dr Francis W Peabody to Harvard students
on October 21, 1927, and the words have
lasted well.1 Although much has changed since
this essay was written, the importance and
appreciation of having or being a good personal
physician has not. The philosophy of medicine
expressed therein, i.e. “. . . for the secret of the
care of the patient is in caring for the patient…”
is more relevant today than in 1927.
But I am not a philosopher. I am a
contemporary family physician and I practice
the well-founded concepts and principles of
general practice that my colleagues have been
following for umpteen years. However, at the
beginning of my career, as a family physician, I
realized that I was practicing a vocation for which
I had not received any special training. I found
 4  Section 1: Basic Principles
many of its principles and practices unique
and new when applying them to unselected
patients with heterogenous problems in an
ambulatory environment. The experience
within the confines of hospital wards, which
provided hardly any formal training in areas
such as family dynamics, behavioural and
social sciences, or health promotion and
prevention made it difficult to unravel the bio-
psychosocial factors involved in the genesis of
illness and diseases in an individual or family.
Many illnesses I encountered were the results of
complex individual or family factors that defied
conventional treatment. Many were ill with
little physical evidence of disease. On many
occasions the relentless search for diagnosis
was self-defeating.
As time rolled by and I started “graduating”
in family practice, I realized that the
fundamental functions of the family physician
go beyond the generic clinical process of
history, physical examination, investigations,
diagnosis and treatment, which is emphasized
in the management of “cases” we see in the
wards. Rather, the clinical acumen required of
a family physician need distinct approach and
special skills in eliciting concerns, focusing on
the key issues to negotiate plans, and helping
solve problems by sharing responsibilities,
and managing uncertainties. The focus is on
the individual or family members , requiring
refined interpersonal abilities for observing and
seeing, listening and hearing, understanding,
finding meaning and, most of all, caring.
The essence of our clinical methods in
general practice is that the body, the emotions,
and the patient’s experience of illness are
attended in every case; the degree of attention
obviously depending on the individual
circumstances. If we are to be healers, we
need to know our patients as individuals;
they may have their illness in common, but in
their response to illness they are unique. Even
in a relatively minor condition, the illness is
assessed as a whole, including an assessment
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of doctor-patient relationship. This, Prof. Dr.
McWhinney has proposed as an “orgasmic
view”,2 that is an organism reacts to the traumas
of life as a whole; all significant illness affects
the organism at every level, from the molecular
to the cognitive and affective.
Over the years these reflections changed my
attitude to illness and sufferings, and also my
relationship with patients. I began, as did most
general physicians, to develop a continuing
relationship with my patients who returned to
me with different complaints and illnesses. As
I became increasingly familiar with individual
family members that I cared for, I began to see
the family as more than simply a collection
of individuals. Instead, I became aware of
the unique interactions and dynamics within
each family and realized that family is a living
unit and basic social group of society, which
influences health status and health behavior of
people. Through them we have an opportunity
to learn about shared human experience. Both
the patient and the doctor transcend to a point
of recognizing and understanding each other.
In family practice this mutual recognition
and trust translates into profound respect for
the doctor-patient relationship. Recognition
does not merely involve seeing the patient in
a whole sense, but also involves recognition
of the doctor as a whole personality. Both the
doctor and the patient appreciate and share
this process, which develops gradually and
almost subconsciously. Both the doctor and
the patient are enlightened and enriched by the
intimate process of personal discovery of trust
and respect. Although physical examination
and clinical diagnosis were important, the
subtle elements that influenced patient’s illness
outcomes became interwoven with a life story.3
Thus, sharing the past and future with
patients, I gained an insight in their unique
medical history and personal circumstances.
I learnt how family physicians help interpret the
symptoms, monitor the course, and raise alerts
to action when needed. Even when a person
 Chapter 1: Philosophy of Family Medicine 5

is terminally ill, the efforts concentrate on the
potential of life’s sustenance. Deliberately
involving in the last stages of another person’s
life, investing time and energy, and to become
attached to someone who will soon die is a
daring and courageous act. As physicians we
are deprived of our “bag of tricks” and have
no cure to offer for our patients at their end-
of-life existence. Our knowledge of drugs and
available support services may ease patients’
suffering but, more than anything else, it is our
attentive concern and love that are helpful to
the patient. In this process family physicians
shares the pain, distress and suffering along
with the bedridden and their family. In
this turmoil of human existence everyone
experiences to have “gained” something in a
situation traditionally considered one to solely
of “loss”. During this sojourn, we, as physicians,
are not expected to “know everything”; we are
expected to share our knowledge to the extent
that is useful, but more importantly, we are
expected to share our human understanding.3
For patients, the “good” doctor recognizes
the common frailty and the humanness within
each person and develops empathy and
respect for every person. Patients recognize
their doctors may make mistakes and miss
diagnosis. No one can be perfect no matter
how hard they strive to be. But the impact is
more tolerable, as both doctor and the patient
recognize each other and all are participants
together in the process of human sufferings.3
Family physicians have the ongoing long-
term contract with patients through thick and
thin, and most specifically, in situations where
medical treatment has “failed”. It not only fails
the patient, but also the doctor, who has until
then based his/her whole working relationship
on the implicit promise of treatment and
cure. When therapy fails, physicians must
find other ways to be with the suffering soul
and their families. Gayle Stephens recognized
that “patient management does not equal
treatment but is a much broader concept,
including when to treat, when not to treat,
and how to take responsibility over time for a
string of treatment choices.”4 Sooner or later,
physicians, after many such experiences,
realize that, “medicine sometimes cures, often
relieves, but always consoles”, and discover
the extraordinary experience of sharing the
human process of life and death. Birth, joy,
strength and success are as integral as pain,
suffering, weakness and dying. Being there
for the patient and the family at these times is
part of the privilege and the process of family
practice. You can pretend to know, you can
pretend to care, but you cannot pretend to
be there. It is by being there for patients that
the family doctor provides the needs patients
seek: touch, trust, understanding, comfort and
healing. No substitute suffices.3
This then becomes the basis of what
constitutes the “Philosophy of Family Practice”
and what it sets apart from other branches of
medicine.
The number of specialties in medicine has
grown significantly over the past several years.
At this time, there are numerous specialties
and sub-specialties recognized by medical
fraternity all over the world. Yet, family medicine
transcends them all. As Howard Stein argues
so cogently, “Our legitimacy lies not in the
ownership of disease entities or social units,
but in the world-view of inter-relatedness
which we reintroduce into medicine. If we are
able to resolve our identity conflict without
choosing either of these two extreme solutions,
— i.e. amalgam and specialty myth* — family

*The "Amalgam Myth" states that family medicine is simply a melding together of the major clinical
disciplines along with some behavioral science … family medicine is seen as nothing more than the sum
of its parts; it consists of the "easy parts" of each of the specialties it comprises. The "Specialty Myth" is
an attempt to achieve credibility with other academic colleagues and status in the eyes of the public, and
thus claim to the family as an area of expertise and become just another specialty.

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 6  Section 1: Basic Principles
medicine can fulfill its promise of becoming
a discipline that transcends specialties as it
integrates them into a new whole.”5 Further
Edmund Pellegrino, MD, observed: “Human
diseases do not come in neatly labeled
categories nor are humans so tractable as to
develop disorders in only one organ system at
a time. The very development of specialization,
while essential, only accumulates the need for a
corresponding development of the integrative
functions of the generalist.”6
What Dr Francis Peabody foresaw over
eighty years ago still holds true today: "Never
was the public in need of wise, broadly-trained
advisors so much as it needs them today to
guide them through the complicated maze
of modern medicine. The extraordinary
development of medical science with its
consequent diversity of medical specialists
and the increasing limitations in the extent of
special fields—indeed, the very factors which
are creating specialists in themselves—create
a new demand. Not for men who are experts
along narrow lines but for men who are in
touch with many lines."
Family medicine represents an approach
to patients, which is open-ended and not
delimited by discipline: the commitment is
to the patient, not to a body of knowledge.
Anything the patient wants to talk about is
relevant. Caring and compassion are valued
more highly than the ability to recite the latest
facts. This concern of general practitioners
toward total management of patients and
family members completes their transition
from a general practitioner to a family doctor.
It is over forty years since family medicine
became a recognized specialty.7,8 However,
medicine is standing at its crossroads today.
The science of medicine and its organization
have been changing expeditiously. Although,
the specialty of family medicine remains
grounded in providing comprehensive,
continuous, compassionate care in the
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context of the family and community, “the
shifting sands of the beaches and remodeling
of the shoreline reminds us that changes
occur over time.”9 While the improvements in
medical technological progress and scientific
discoveries are promising, it is regrettable
that the absence of warmth is sorely missed
in the present day health care to the needy.
The art of healing has been transformed to a
highly specialized one, utilizing sophisticated
machinery linked to the electronic age. Too
often the patient is lost or forgotten in the
process of hi-tech diagnosis and treatment.
Decisions are now based on computer
printouts, resulting in doctors becoming part
of the robotic process themselves, becoming
dehumanized to the extent that he comes to
rely on miracle drugs and wonder machines
becoming oblivious of the Supreme Healer.
Herb Fred10, in his article “The Tyranny of
Technology”, coins the term “technologic
tenesmus” to describe the uncontrollable urge
to rely on sophisticated medical gadgetry for
diagnosis. The challenge, therefore, is to use
technology to enhance the fundamental goals
and principles of Family Medicine rather than
have technology dictate or interfere with our
primary mission.11
Our forebears in general practice and the
founding leaders of family practice movement
understood the need for physicians who
practice medicine with both science and care.
“By its traditions and very nature, medicine
is a special kind of human activity — one
that cannot be pursued effectively without
the virtues of humility, honesty, intellectual
integrity, compassion, and effacement of
excessive self-interest. These traits mark
physicians as members of a moral community
dedicated to something other than its own
self-interest”. 12 These principles are more
important than ever as we face the changing
currents in the complex world of health care
in this new century.
 Chapter 1: Philosophy of Family Medicine 7
References
1. The Caring Physician: The Life of Dr. Francis
W. Peabody. N Engl J Med. 1993;328:817–18.
2. McWhinney IR. Being a General Practitioner:
What it means. Oration given at the 2000.
WONCA European Conference. Vienna.
3. Woolford P. Thesis in Philosophy of general
practice. NZFP. 2002:29(1).
4. Stephens GG. The Intellectual Basis of Fam.
Med. Revisited; Fam Med. 1998;30(9):642–54.
5. Stein HF. Family medicine as a meta-specialty-
and the dangers of over definition. Fam Med.
1981;13(3):3–7; as quoted by Wayne Weston in
“The foundations of curriculum for PG education
in Fam Med., Dept. of Fam Pract. Residency
Program, The Univ of British Columbia. 2000.
6. Brody H, Edmund D. Pellegrino's philosophy
of family practice. Theor Med. 1997 Mar-
Jun;18(1-2):7–20.(PMID:9129389:Abstract).
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7. Web site : http://www.rcgp.org.uk/about_
us/history_heritage__archives/history__
chronology/history_essay.aspx (accessed on
21-09-2011).
8. Web site: http://fmignet.aafp.org/online/
fmig/index/family-medicine/defining-the-
specialty/history-scope-resources.html
(accessed on 21-09-2011).
9. Philips WR et al. The domain of family
practice; scope, role, and function. Fam Med.
2001;33(4):273–77.
10. Fred HL . The tyranny of technology.
Hosp Pract (Off Ed). 1997;32(3):17–8,21
(PMID:9078964:Abstract).
11. Ebell MH, et al. What can technology do to,
and for, family medicine? Fam Med. 2001;
33(4):311–9.(PMID:11322524:Abstract).
12. Cranshaw R, et al. Patient-physician covenant.
JAMA. 1995;273:1553.
 2 Scope of
“The education of the doctor which goes on after he has his degree is, after all,
the most important part of his education.”
Introduction
All around the world, family physicians
are recognized as the essential link in the
health care system. They work as an interface
between the community on one hand and
the health care system on the other. They
are the doctors of first contact and provide
primary, continuing, comprehensive, and
coordinated care for patients and families in
their community setting. They are strategically
placed to understand the health care needs
of the community and how the health care
system can meet them.
Family, the basic unit of society, is the most
fundamental foundation, which influences
health status and health behavior of people.
Therefore, it should be the focal point of health
care delivery. Obviously, family medicine
is neither a disease oriented nor a human
organ oriented specialty; rather it is a health
care centered on family as a unit. In the most
comprehensive sense, the aim of family
medicine is to promote positive health care of
all family members, diagnose and treat disease
at its early stage, minimize disability and also
help in rehabilitation, if necessary. Therefore,
the scope of practice is extended from personal
care to family care, from first contact to an
ongoing care, and from curative to health care
prevention and rehabilitation.
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Family Medicine
— John Shaw Billings (1838-1913)
Three Facets of Family Practice
Typically, family practice consists of three
characteristic aspects, namely: Knowledge,
skill and process knowledge, skill, and
process.1 While knowledge and skill may be
shared with other specialties, the “process” of
family practice is unique. At the center of this
“process” is the patient-physician relationship
with the patient viewed in the context of
the family.  It is the extent to which this
relationship is valued, developed, nurtured
and maintained that distinguishes family
practice from all other specialties. The family
physician must accomplish this function in the
framework of an increasingly complex social
system, characterized by rapid technological
advances, taking into account the changing
patterns of illness and changing expectations
about health.
In the “process” of caring for the whole
family, family physicians not only gain
knowledge, but also enlarge their scope of
action. Whenever situation arises, they can
change their focus from individual to family
and back again. In many situations in which
illness of an individual is followed by family
dysfunction, they can quite readily direct their
actions to the family as a whole.
The family physician’s personal knowledge
of patients is a confidential information about

particular patients who the physician has
cared for over a series of encounters spanning
several years. It is a detailed portrait painted
with layers of fact, intuition, and experience
and is comprized of a mix of clinical art,
science, psychodynamics, and ethics.2 This
personal knowledge can be used in making
hypothesis about problems they encounter in
the family.
Matrix of Family Practice
Family physicians refer patients when
indicated to other sources of care while
preserving continuity of care. The family
physician’s role as a cost-effective coordinator
of the patient’s health services is integral to the
care provided. If the patient is hospitalized,
this role prevents fragmentation and lack of
coordination of care. This role also allows
the family physician to serve as the patient’s
advocate in dealing with mediclaim insurance
and managed care policies that are in vogue in
many countries.
The form of family practice follows the
function of family physicians. Family physicians
acquire and maintain a broad and varying array
of competencies, depending on the needs of
the population they serve, the communities in
which they practice, and the environments in
which both they and their patients work and
live. Therefore, although all family physicians
share a core of information, the dimensions of
knowledge and skill vary with the individual
family physician based on patient’s needs
and the physician’s continuing education.  As
patient’s needs differ in various geographic areas,
the content of a family physician’s practice and
scope varies accordingly. At one end are family
physicians who may be the only local source
for health care for their community. Besides
attending patients in outpatient department,
they look after trauma cases, deliver babies, care
for the seriously ill patients in hospital units,
stabilize patients for transport if necessary, and
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Chapter 2: Scope of Family Medicine 9
perform autopsies too. Family physicians with
such skills and capabilities are common in rural
areas. At the other end of the spectrum are family
physicians who limit their care to office practice
and coordinate comprehensive care for their
patients in a multi-speciality group.
Furthermore, the speciality of family
medicine is ever changing.  Depending on
the needs of the patient and the resources
required, family physicians provide definitive
care, shared care, supportive care, or direct the
care provided by their colleagues. The Keystone
III conference3 held at Colorado to discuss
family practice in United States and its status
after thirty years of development found that
the emerging generation of family physicians
(generation three) sees family practice in a
wider variety of roles, choosing academics or
research or public administration. They can
be teachers to all their patients and to many of
their colleagues. Family physician may also be
a scientist, scholar and advocate of health care
organizations and committees, chairing either
independently or collectively, and helping
to define the policies for the future of family
practice. Some family physicians develop an
area of special interest and expertise, such
as sports medicine, geriatrics, preventive
care, international health, women’s health,
adolescent health or emergency medicine.
Family physicians who maintain a broad
scope of practice may find themselves better
positioned to demonstrate their relative value
in the new century and justify higher incomes
as the health care system continues to change
(Fig. 2.1).
The family physician’s practice continually
evolves as competency in current skills is
maintained and new knowledge and skill
are obtained through continuing medical
education.  This growth in medical information
also confers on the family physician a
responsibility for the assessment of new
medical technology and for participation in
 10  Section 1: Basic Principles
Fig. 2.1  Family medicine—scope
resolving ethical dilemmas brought about
by these technological advances. Although
family physicians should exploit the expanding
technologies in the field of information and
communication, they must guard against
displacing the essence of patient-physician
communication.
Proactive Role of Family Physician
At present, family physicians have been
devoting most of their attention to curative
medicine. But with the rapid changes in
society, they are now obliged to get away from
this traditional pre-occupation of diagnosis
and treatment, though they are essential, to
meet a more urgent challenge of keeping their
patients in a state of complete well-being,
using every paraphernalia at their disposal.
Thus, medicine today is no longer on the
defensive in the fight against disease and its
consequences and sequelae, but is now on the
offensive with a positive dynamic promotion
of optimum health. As the 20th century
progressed and scientific medicine advanced
and differentiated, the pattern of health care
has changed dramatically. The concept of
general practitioner has emerged in a new form
with several disciplines to what has come to be
called “primary care”, providing broad-based
care to their patients and families over long
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periods of time. The goal of modern medicine
is no longer merely treatment of sickness. The
more important goals that have emerged are
prevention of disease, promotion of health and
improvement of quality of life of individuals
and groups or communities. It is this move
from curative to preventive to promotive
medicine that family physicians have to adopt,
if they have to survive in their role of a friend,
philosopher and guide to the family under
their care. Therefore, family physicians have to
be the best health educator of the family. The
ideal patient-doctor relationship that exists—
the confidence and the respect they have in
their physician—can build an ideal house of
perfect health; and to achieve this goal, the
family physician can use health education as
an effective tool.
Above all, the scope of family practice
is dynamic, expanding, and evolutionary—
encompassing healthcare for all the major
events of the family—marriage, birth, infancy,
childhood, adolescence, adulthood, aging,
trauma, illness and death. Care devoted to the
patient as a “whole person” all through these
phases of life cycle enriches the knowledge
of the family physician as well. The family
physician need not be all things, to all people
all the times. He or she should, however, try to
bring something special to each patient, each

encounter and something more over time.
“What keeps the doctor devoted to the patient
is the reflection at the end of the demanding
day that he or she made a difference in
the life of an important person. For the
family physician this reward is enhanced by
understanding the patient’s life, knowing the
family, and livelihood in the community.”4
Conclusion
In summary, the scope of family medicine is
extended from personal care to family care,
from first contact care to an ongoing care, and
from curative to a comprehensive health care,
i.e. from health prevention to rehabilitation.
In recent years the rapid growth in medical
technology and information confers on family
physicians the responsibilities to judiciously
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Chapter 2: Scope of Family Medicine 11
incorporate them to survive in their role of a
friend, philosopher, and guide to the families
under their care.
References
1. American Academy of Fam. Phy. Reference
Manual. Family Medicine, Scope and
Philosophical Statement Web site: http://www.
aafp.org/online/en/home/policy/policies/f/
scopephil.html (accessed on 24-09-2011).
2. Weyrauch KF. The personal knowledge of
family physicians for their patients. Fam
Med. 1994;26(7):452–5. Review. (PMID:
7926363:Abstract).
3. The Robert Graham Center, Keystone III,
Cheyenne Mountain Convention Center,
Colorado Springs, Colorado. 2000;4–8. 
4. Phillps WR, et al. The domain of family practice.
2001;33(4):273–7.
 3 FAMILY MEDICINE—THE
RISING DISCIPLINE

“Medicine arose out of the primary sympathy of a man with man; out of the
desire to help those in sorrow, need and sickness.”
“The basis of medicine is sympathy and the desire to help others and
whatever is done with this end must be called medicine.”
— Sir William Osler, “The Evolution of Modern Medicine.”
Yale University, April 1913.

History the time of Henry VIII. They had graduated

The origin of medicine can be traced to the
evolution of mankind. Throughout history
people have tried to cure illness and restore
health. The development of modern medicine
is not only linked with old magical rites and
religious creeds with primitive opotherapy
and classical Hippocratism with dogmatic
doctrines and revolutionary discoveries, but it’s
also intimately associated with the economic,
intellectual and political conditions at different
times including the past traditional cultures and
knowledge of eminent individuals.
The history of “General Practice” as a
specific discipline is long and tortuous.1 The
first physicians were “generalists” (general
practitioner* is derived from the Latin word
“genus”, meaning “generalis” and the Greek
word “praktikos” meaning “practice”). For
thousands of years, these generalists provided
all of the medical care available.  craftsmen and carpenters by profession.
The modern Anglo-Saxon medical system we
know today has its roots in three main groups:
1. The Physician—Initially there were
physicians whose charter dated back to
from universities and looked after the
health of wealthy population. They did not
dispense medicine, did not mix freely with
other health professionals and labor class
of society. They did not do any surgery. The
leading physicians of the time wanted the
power to grant licenses to those qualified
to practice medicine. “Six physicians, three
of them Court physicians, petitioned on
behalf of the physicians of London that they
might be incorporated as a college. Their
leader was Thomas Linacre, who became
the first president.”2 By royal charter of King
Henry VIII in 1518 they formed “The Royal
College of Physicians,” London.
2. The Surgeons — In the mid 14th century,
there was a separation between medicine
and surgery, the latter having fallen into
disrepute with operations being carried
out by manual workers who were barbers,
This was a form of specialization. In fact
in 1462, King Edward IV of England gave
the right to practice surgery to the Barbers’
Company instead of the Surgeon’s Guild

*The term general practitioner first came into use around 1810.

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 Chapter 3: Family Medicine—The Rising Discipline 13
and this status quo existed till 1745, when
the surgeons broke away from the barbers
to form the Company of Surgeons. In 1800
the Company was granted a Royal Charter
to become the Royal College of Surgeons in
London, which later amended its charter to
become “The Royal College of Surgeons of
England” in 1843.3,4
3. T h e Ap o t h e c a r i e s 5 —T h e “g e n e ra l
practitioner” is a direct descendent of
the “apothecary”, which comes from the
Latin word apotheca, meaning a place
where wine, spices and herbs were stored.
The origin of apothecaries dates back to
mediaeval times from the itinerant medicine
sellers, known as Grocers, Pepperers, and
Spicers. During the thirteenth century in
United Kingdom, some persons kept a
stock of these commodities which they sold
from their shops or street stalls. By charter
in the year 1617 the medicine sellers were
allowed the exclusive right to keep a shop
with bottled leeches and lotions of various
kinds. From 1672 until 1922, the Society
of Apothecaries manufactured and sold
medicinal and pharmaceutical products at
the Apothecaries’ Hall*. Quick to keep them
in their place, the physicians obtained an
order, forbidding apothecaries to prescribe
medicine; but in 1664 the Great plague
pandemic—“the black death”—turned the
tables. It was noted that qualified physicians
had been the ones who picked up their gear
and left town, most physicians had fled the
city for their own safety, leaving the sick and
healthy behind; at a time when they were
most needed, while the apothecaries stayed
to care for the ill.6, 7
*The Society's Hall in Blackfriars, UK, formerly the guesthouse of the Dominican Priory of the Black
Friars, was acquired in 1632. Destroyed in the Great Fire of London, it was re-built by 1672 on the same
site, where it still stands.
**The Rose case of 1703–04: Apothecaries were permitted to charge for medicines but not for medical
advice or diagnosis.
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In 1704 the Society won a key legal suit
(known as the Rose Case) against the Royal
College of Physicians in the House of Lords,
which ruled that apothecaries could both
prescribe and dispense medicines. This led
directly to the evolution of the apothecary into
today’s general practitioner of medicine.
Just over a century later, as a result of
the Apothecaries’ Act of 1815, the Society
was given the statutory right to conduct
examinations and to grant licences to practise
medicine throughout England and Wales, as
well as the duty of regulating such practice.
The Apothecaries Act of 1815 declared
that only those licensed by the Society of
Apothecaries could legally practice as one.
Becoming registered involved a 5- year
apprenticeship, a 6-month hospital attachment
and final exams. This was a momentous step
that gave apothecaries standing in their own
right. In 1830, following the test case called
Rose case in the courts** where an apothecary
successfully sued an attorney for the bill for his
professional services. The editorial of the Lancet
proclaimed that, “the subordinate members of
the profession, i.e. the “general practitioners”,
have been raised 1,000 degrees in the scale of
professional respectability and 10,000 degrees
in the estimation of society.” This decision in the
Rose case gave legal confirmation to the role of
apothecary as ‘general practitioners’ rather than
tradesmen. This was the first usage of the term
“general practitioner” and it has remained the
common descriptor ever since.8
The General Medical Council (GMC)
was established under the Medical Act of
1858 in England which exclusively maintains
the standards and discipline of the medical
 14  Section 1: Basic Principles
profession. It specifies the requirements for
training and examination of anyone who
would be allowed to become a doctor. Indeed it
allowed general practitioners to be addressed
with the title of “doctor”, although the College
of Physicians fought a 50-year battle against
this. Women were allowed to join from 1876,
and there was resistance against this move too.
Thus, in the beginning of the 19th century
there were three distinct classes of medical
practitioners comprizing of the physicians,
surgeons (who by then had taken over from
the barbers), and the apothecaries. Each had
its own governing body with licensing rights,
which ensured that minimum standards were
kept. In 1815, the Apothecaries Act made it
compulsory for apothecaries to undergo a
5-year apprenticeship in anatomy, physiology,
clinical medicine and materia medica, which
was essentially an index of the remedies
available then. It also established a qualifying
examination, the Licentiate of the Society of
Apothecaries (LSA). It is sometimes argued
that the Apothecaries Act of 1815 was not
only the generator of medical education as
known today, but that it also led toward a
united medical profession by transforming
the general practitioner into a scientifically
trained professional man. In 1858 the General
Medical Council made it compulsory for all
practitioners to pass final examinations in the
three main subjects of medicine, surgery and
midwifery. “Lancet” coined the term ‘general
practitioner’ for them in 1823.1
Early 20th century was the beginning of
the golden era of general practice, and general
practice as a whole was thriving. Medicine was
practiced as a blend of science and art. The
general practitioners were known as family
doctors.
Age of Specialization
The next phase of development was the age of
specialization.
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As 20th century progressed and scientific
medicine advanced, specialty medicine was
born and the pattern of medical care changed
dramatically in many European and Asian
countries. Medical knowledge expanded and
technology advanced and many physicians
chose to limit their practices to specific,
defined areas of medicine.  With World War II,
the age of specialization began to flourish.  In
the two decades following the war, the number
of specialists and sub-specialists increased at a
phenomenal rate, while the number of general
practitioners declined dramatically.  The
proverbial art and science of medicine moved
from “organisms to organs, from organ to the
cell, and from cell to molecular and genetic
levels.” 9 The public became increasingly
vocal about the fragmentation of their care
and the shortage of personal physicians
who could provide initial, continuing and
comprehensive care.  This fragmented system
of the health care needs of the common
household people has been explained in an
anonymous practitioner’s letter in 1850, which
states:
“The countess of A, or Mrs B the city
millionaire’s wife, has a physician for one
complaint, a surgeon for another, a physician
accoucher for a third; and an apothecary,
probably provides the medicines and attends
the children and servants. But how is this
possible for a person in ordinary circumstances?
It is, therefore, absolutely necessary that, to
supply the wants of the middle and lower
classes in the metropolis, and of nearly all
ranks in the provincial towns and villages,
there should exit a branch of the profession,
the members of which must be competent to
undertake the management of all diseases.”10
Some critics described this “hi-tech”
medicine as a threat to the health of the
population at large, leading the health system
in the wrong direction, i.e. away from the
health promotion for the many and toward
 Chapter 3: Family Medicine—The Rising Discipline 15

expensive treatment for the few. This has been
called as a “failure of success.”11
Way back in 1923, Dr Francis Peabody,
Prof. of Medicine at Harvard, commented
that specialization in medicine had already
reached its apex and that modern medicine
had fragmented the health care delivery system
to too great a degree. He called for a rapid
return of the general physician who would give
comprehensive and personalized care.
In 1960s, three reports—namely Folson*,
Millis**, and Willard*** committee reports,
along with a generation of visionary leaders
in general practice in United States, such
as Abraham Flexner (1866–1959), who was
responsible for major transformations of
American elementary, secondary, medical,
and postgraduate education made similar
recommendations. 12 The 60s brought the
appropriate social forces, and the right
environment for Family Medicine to be born
as a new specialty. In fact many people see
Family Medicine as one outgrowth of the
“Counterculture movement”, perhaps as a
child of the sixties.13,14,15 This outcry led to the
reorientation of medicine back to personal and
primary care. The concept of the generalist
was reborn with the establishment of family
practice as a specialty.
Thus it can be seen that general practice
and other specialties evolved from different
origins and the evolution was in response to
a need and the expanding pool of knowledge
(Table 3.1). As the frontiers of knowledge are
pushed further, family medicine itself has
evolved into a specialty of its own, requiring
specialist skills and expertize in providing
comprehensive care for the person as a whole.
Revival of Family Medicine
The revival of Family Medicine, brought
about by a confluence of political and social
changes in the 1960s, has been hailed by
communities and supported subsequently by
some governments. The upsurge of interest
was seen especially in USA and United
Kingdom.
In America, the American Academy of
General Practice (AAGP) was founded in 1947
and the first residency training programs in
general practice commenced in 1950. In 1969,
the American Board of Family Practice (ABFP)
was formed and Family Medicine was recognized
as the 20th American medical speciality. Many
approved family practice residencies in the
United States are initiated,16 and the first ABFP
examination took place in 1970. In the same year,
1970, the American Academy of General Practice
changed its name to the American Academy of
Family Physicians (AAFP).11
In the United Kingdom, the Royal College
of General Practitioners was founded on 19th
November 1952. It offers specialty course in

*The Folsom Report. Presented in 1966, this report was sponsored by national public health authorities.
One of the many recommendations of this commission was the concept that every American should have
their own personal physician.
** The Millis Report. Sponsored by the American Medical Association (AMA) and also published in 1966,
the Millis report focused on graduate medical education and encouraged specific efforts designed to
increase the number of physicians who could replace the dwindling reserve of general practitioners. This
report emphasized clinical competence, continuity and prevention.
***The Willard Report. Sponsored by the AMA, the Willard report recommended creating a separate training
track in family practice. It also recommended creating a speciality board to oversee certification in family
practice. The American Board of Family Practice was born in 1969.
(Source: Saultz JW. Family physicians in America: A brief history. An overview and history of the specialty
of Family Practice. In Saultz JW (Ed). Textbook of Family Medicine: Defining and examining the discipline.
New York: McGraw-Hill. 2000;3–16).

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 16  Section 1: Basic Principles
TABLE 3.1  Certain events of importance in the history of evolution of general practice

1462 – King Edward IV of England gave the right to practice surgery to the Barbers’ Company
1518 – The Royal College of Physicians, London formed
1540 – The Company of Barber-Surgeon of London established
1617 – The Society of Apothecaries established
1704 – The Rose case: This landmark ruling formed the basis for the legal recognition of apothecaries as
doctors, and marked the beginning of the general practice of medicine
1745 – Surgeons broke away from the barbers to form the Company of Surgeons
1800 – Foundation of Royal College of Surgeons, London
1810 – The term general practitioner first came into use
1815 – The Apothecaries Act/compulsory 5-year apprenticeship
1815 – The title of Licentiate of the Society of Apothecaries (LSA )
1826 – The Association of General Medical and Surgical Practitioners
1843 – College of Surgeons of England
1855 – British Medical Association
1858 – General Medical Council was established in England
1876 – Women were allowed to join
1923 – Dr. Francis Peabody, Prof. of Medicine at Harvard, called for return of the general physician
1907 – LSA title altered to LMSSA, indicating inclusion of Medicine and Surgery
1928 – Apothecaries Society administers postgraduate diplomas in 12 specialist subjects
1947 – American Academy of General Practice (AAGP) was founded
1950 – First residency training programs in general practice commenced in USA
1952 – Royal College of General Practitioners’, United Kingdom, was founded on 19th November 1952.
1958 The Australian College of General Practitioners was formed
1960 – Three reports – namely Folson, Millis, and Willard committee reports in United States recommend
return of the general physician
1963 – Indian Medical Association (IMA) started the College of General Practitioners
1969 – American Board of Family Practice (ABFP) was formed
1969 – Family Medicine was recognized as the 20th American medical specialty.
1970 – First ABFP examination/certification took place
1971 – AAGP changed its name to the American Academy of Family Physicians (AAFP)
1971 – The College of family Physicians Singapore formed
1972 – WONCA was founded
1978 – The Declaration of Alma Ata: The International Conference on Primary Health Care

General Practice with systematic training
programmes on par with other fellowship
examinations.17
Today, we have our flagship organization,
the World Organization of Family Doctors,
i.e. World Organization of National Colleges,
Academies and Academic Associations of
General Practitioners/Family Physicians -
WONCA)*, which is made up of national
colleges, academies or organizations concerned

*Ref. Appendix 3.

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 Chapter 3: Family Medicine—The Rising Discipline 17
with the academic aspects of general family
practice. Beginning with 18 members in 1972,
there are now 120 member organizations in 99
countries. This includes ten organizations in
collaborative relations with WONCA. In all, the
total membership of the member organizations
of WONCA is over 250,000 general practitioners/
family physicians.18 WONCA represents and acts
as an advocate for its constituent members at an
international level where it interacts with world
bodies such as the World Health Organization.
The family physician constitutes the
fundamental core of the health systems in
Canada, Australia, New Zealand, Netherlands
and Spain. The general practitioner is the key
provider in the National Health System in
the UK. In Cuba, the family physician is the
chief provider in their comprehensive health
plan. The family practice is also active with
university faculty departments in South Korea,
Malaysia, Hong Kong, Singapore, Indonesia,
Taiwan, Philippines, Myanmar, Bangladesh,
and Pakistan. The nature of care varies from
country to country, and may even involve an
active role in hospital care. Thus the nature
of the curriculum of training programmes in
family medicine, the time duration, and the
ratio of preventive/curative care varies from
country to country.19
In countries of South-East Asian region, Sri
Lanka (Family Medicine), Thailand (Family
Medicine), and Nepal (General Practice),
have introduced this discipline as full-fledged
specialties. In 1963, the Indian Medical
Association started the College of General
Practitioners, and since 1977 the College is
conducting its Fellowship examination in
the specialty of Family Medicine. Since 1977
the National Board of Examination, New
Delhi, with training for qualified doctors in
accredited hospital throughout the country,
is conducting a certifying course in Family
Medicine.20,21* This training program is largely
*Ref. Appendix 1 and 2.
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based and delivered through National Board
of Examination—a body of Ministry of Health
and Family Welfare, India, accredited health
institution. Further, the present Indian Medical
Council is in favor of implementing in near
future strategies to ensure proper place for
family doctors in health care delivery systems
by establishing new departments of Family
Medicine in all medical colleges, and the process
of a suitable curriculum of Family Medicine at
undergraduate and postgraduate level is under
preparation.22 The WHO project report on
core curriculum asserts, “The current trend
in specialization with advanced technology,
decentralization and community-based care in
countries of the South East Asia region further
underscores the need to cut across territorial
boundaries of all traditional specialties with
varied clinical skills to promote primary care
in the district health system.”19
From a position during the sixties, when
little if any, attention was paid to the specific
training of the general practitioner/family
physician at either the undergraduate or
graduate levels of medical education, training
programmes in family medicine are now in
the educational limelight. Great progress has
been made to establish family medicine as a
distinct educational discipline. Most medical
schools in developed countries have University
Departments of Family Medicine providing
training programmes in Family Medicine
with teaching responsibilities at both the
undergraduate and graduate levels of medical
education.
Future
“You plant a seed, water it, weed it… but you
don’t grow the seed. All you can do is create
perfect conditions for the universe to grow the
seed for you.”
— Sonia Choquette
 18  Section 1: Basic Principles
The specialty of family medicine was created
in 1960s to meet people’s needs for renewal
of the generalist function in medicine, for a
whole-person focus, and continuity of care that
was comprehensive and coordinated.
It is more than 40 years now that a phase
has reached to assess whether these core
attributes were still integral to both how
physicians approached their practice and to the
patients they care for. “It is widely recognized
that family medicine now faces substantial
challenges that imperil its future (Table 3.2).
Today, high-tech and sub-specialty medicine
plus chronic disease management are the foci
of most academic health centers and large
hospital systems, while primary care, including
family medicine, often is not considered a
key component of medical care. Addressing
these challenges will require an examination
of the present system incorporating health
care economy, our training model, our basic
principles, and our model of care delivery
(Table 3.3).”23
Further, the “Future of Family Medicine
(FFM) Project Leadership Report” identifies
five challenges affecting our future viability:24
1. Promoting a broader, more accurate
understanding of the specialty among the
public.
2. Identifying areas of commonality in a
specialty whose strength is its wide scope
and locally adapted practice types.
3. Winning respect for the specialty in
academic circles.
4. Making family medicine a more attractive
career option, and
5. Addressing the public perception that
family medicine is not solidly grounded in
science and technology.
The FFM Project Leadership Committee
concluded that changes must occur within
the specialty, as well as within the broader
health care system, to ensure the ability of
family medicine to meet these challenges and
continue to fulfill its unique mission and role.
Showstack et al 25 suggests seven core
principles (and a set of actions) that will
support a renaissance in, and a positive future
for primary care. The seven principles are:
1. Health care must be organized to serve the
needs of the patients.

TABLE 3.2  Major challenges facing family medicine

Generating an understanding of family practice

Despite its 30-year history, neither the general public nor health care professionals understand all that family
practice represents.
Organizing individuality. There is significant variance in practice scope from one family physician to the next.
As a specialty, family medicine has deliberately resisted specific definition from the beginning.
Winning respect in academic circles. Family medicine suffers as a result of not having gained the respect
and resultant endorsement of key academic institutions. Some medical schools feel that family medicine will
bring neither money nor recognition to the school; as a result, they neither support the specialty nor encourage
students to pursue it.
Making family medicine an attractive career option. Issues requiring attention include: inadequate
remuneration, little recognition in the medical field, managed care challenges, quality of care yielding to
pressures to increase the quantity of visits, and specialists thinking general internists are better diagnosticians
than family physicians.
Addressing the obsession with science and technology in the United States. Family medicine is associated
with neither; some people think family physicians are old-fashioned and cannot handle more critical health
issues. There is a conspicuous absence of family medicine breakthrough research.

Source: Report of the Task Force on Patient Expectations, Core Values, Reintegration, and the New Model of
Family Medicine. Task Force 1 Writing Group* Annals of Family Medicine 2:S33-S50 (2004) © 2004 Annals of
Family Medicine, Inc. doi: 10.1370/afm.134

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 Chapter 3: Family Medicine—The Rising Discipline 19
TABLE 3.3  Family medicine: Traditional vs new model of practice
Traditional model New model
Systems often disrupt the patient-physician relationship Systems support continuous healing relationships
Care is provided to both sexes and all ages; includes Care is provided to both sexes and all ages; includes
all stages of the individual and family life cycles in all stages of the individual and family life cycles in
continuous, healing relationships continuous, healing relationships
Physician is center stage Patient is center stage
Unnecessary barriers to access by patients Open access by patients
Care is mostly reactive Care is both responsive and prospective
Care is often fragmented Care is integrated
Paper medical record Electronic health record
Unpredictable package of services is offered Commitment to providing directly and/or coordinating
a defined basket of services
Individual patient oriented Individual and community oriented
Communication with practice is synchronous (in person Communication with practice is both synchronous and
and by telephone) asynchronous (e-mail, Web portal, voicemail)
Quality and safety can be assumed Processes are in place for ongoing measurement and
improvement of quality and safety
Physician is the main source of care Multidisciplinary team is the source of care
Individual physician-patient visits Individual and group visits involving several patients
and members of the health care team
Consumes knowledge Generates new knowledge through practice-based
research
Experience based Evidence based
Haphazard chronic disease management Purposeful, organized chronic disease management
Struggles financially, undercapitalized Positive financial margin, adequately capitalized

Source: Future of Family Medicine Project Leadership Committee. The future of family medicine: a collaborative
project of the family medicine community. Ann Fam Med. 2004; 2(Suppl 1):S3-S32.

2. The goal of primary care systems should
be the delivery of the highest quality care
as documented by measurable outcome.
3. Information and Information systems are
the backbone of the primary care process.
4. Current health care system must be
reconstructed.
5. Health care financing system must support
excellent primary care practice.
6. Primary care education must be revitalized,
with an emphasis on new delivery models
and training in sites that deliver excellent
primary care, and
7. The value of primary care practice must be
continually improved, documented, and
communicated.
Learning to be a family physician requires
a change of perspective that can only take
place where the new perspective is dominant.
If family physicians are to have certain values
and certain ways of thinking and feeling,
they must be educated in a setting in which
these qualities are all pervasive. And their
teachers must be people who exemplify these
qualities and are respected as role models.26
The solution must lie, first and foremost, with
education and training for the discipline of
family medicine at both undergraduate and
graduate levels of medical education. The
curriculum should provide efficient, quality,
and cost-effective health care system that is
family and community oriented and focused

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 20  Section 1: Basic Principles
on personal service. So, the Reorientation of
Medical Education (ROME)27 may significantly
contribute to producing future doctors with a
new role, with a new knowledge and skill mix,
having attributes of care provider, decision
maker, communicator, and community advisor
that are central to optimum medical practice.
The skills the physician needs can be learned
through experience, sharpened through
practice, and focused through specialization.
According to Larry Green, Director, The
Robert Graham Center for Policy Studies in
Family Practice and Primary Care, Washington,
DC; Keystone III Conference, Oct. 2000,28
“This is another of those tumultuous times
in all of medicine. Most disciplines, not just
medicine, and most specialties, not just
family practice, are being confronted with
having to consider their values, their purpose,
their methods, and the best way to organize
themselves to do their work…. It’s difficult
to accomplish the objectives of primary care
because the ‘system’ doesn’t support doing it.
Primary care’s salutatory effects depend in part
on a trusting, sustained partnership between
doctors and patients, but the system constantly
thwarts this…The system is broken, not the
specialty.”
“Experience in several countries has
demonstrated clearly that what is needed for
spectacular success is the support from the
government, both ideologically and financially
(Table 3.4). Once a government takes the
decision that family medicine will be the base
on which its health system will be built, and
properly fund its development, progress will
be both rapid and far-reaching.”29
Family Medicine—Need of the
Hour
It is common knowledge that the major
challenge in health care is in ensuring sound
and competent basic health care to the
disadvantaged communities, both rural and
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TABLE 3.4  Strategies for successful family medicine
development
Obtain political and financial support for universal
access to primary care.
Integrate clinical and community health care delivery.
Upgrade the status of general practitioners.
Develop family physician faculty and clinician role
models.
Develop undergraduate (medical school) curriculum.
Develop postgraduate (residency) curriculum.
Engage sub-specialists in training and work with
family physicians.
Develop organizations of family physicians.
Establish speciality board certification with national
medical society status.
Encourage governments to take a more active role.
Involve leadership of international health organiz­
ations.
Work with leadership of international family medicine.
Source: Cynthia Haq et al. Family practice development
around the world. Family Practice © Oxford University
Press 1996;13(4):351–6.
urban. Further, even for those who can afford
expensive specialist health care, continuous
and quality assured basic care is essential.
To ensure continuity of care for all
members of the family, of all ages, and to
address all common and urgent medical
conditions cost-effectively, the specialty of
Family Medicine should be taught through a
significant exposure to secondary and primary
levels of care and introduced as a required part
of the medical curriculum. Without this, the
new generation of medical graduates will not
be the basic doctors who form the backbone of
a sound health care system all over the world.
This has been most aptly described below:
“The patient lacked the guidance of a sound
general practitioner who understood his
physical conditions, his nervous temperament
and knew the daily life. And many a patient,
who on his initiative has sought out specialists,
has had minor defects attenuated so that they
assume a needless importance, and has even
 Chapter 3: Family Medicine—The Rising Discipline 21
undergone operations that might well have
been avoided. Those who are particularly
blessed with the world’s goods, who want the
best regardless of the cost and imagine that they
are getting it because they can afford to consult
as many renowned specialists as they wish, are
often pathetically tragic figures as they veer
from one course of treatment to another. Like
ships without a guiding hand upon the helm,
they swing from tack to tack with each new
gust of wind but get no nearer to the Port of
Health because there is no pilot to set the general
direction of their course.”
Dr Francis Peabody
References
1. Loudon ISL. The James Mackenzie Lecture 13
November 1982. Journal of the Royal College
of General Practitioners, 1983;33:13–18.
2. George Clark. History of the Royal College of
Physicians of London. Br Med J. 1965;1(5427):
79–82. [PMCID: PMC2165065:Abstract].
3. Robinson JO. The barber-surgeons of
London. Arch Surg. 1984;119(10):1171–5
[PMID:6383267].
4. Web site - http://www.rcseng.ac.uk/about/
history (accessed on 26-09-2011).
5. http://www.apothecaries.co.uk/index .
php?page=6
6. http://www.britainexpress.com/History/
plague.htm
7. http://www.historylearningsite.co.uk/plague_
of_1665.htm
8. IS Loudon James Mackenzie Lecture. The
origin of the general practitioner. JR Coll
Gen Pract, 1983;33(246):13–23. [PMCID:
PMC1972623:Abstract]
9. Park K. Park’s Text Book of P&PM, 16 th ed. 8.
10. “A Practitioner” Is the practice of Medicine in
1850 a degenerate pursuit? London, 1850.
11. Park K. Park’s Text Book of P & PM, 16th edn. 8.
12. Graham R. et al. Family Practice in the United
States: A Status Report JAMA. 2002;288:1097
–1101.
13. Stevens R. The Americanization of Family
Medicine: Contradictions, Challenges and
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Change, 1969–2000 Fam Med. 2001;33(4):
232–43.
14. Magill M, et al. What Opportunities Have We
Missed, and What Bad Deals Have We Made?
Fam. Med, 2001;33(4):268–72.
15. Stephens G. Family Practice and Social and
Political Change Fam. Med. 2001;33(4):248–51.
16. http://www.aafp.org/online/en/home/
residents/match/summary.html (Accessed on
27-09-2011).
17. h t t p : / / w w w . rc g p - c u r r i c u l u m. o r g . u k /
(accessed on 27-09-2011).
18. ht t p : / / w w w . g l o b a l f a m i l y d o c t o r. c o m /
aboutWonca/aboutwonca.asp?refurl=aw
(Accessed on 27-09-2011).
19. WHO Project No. : ICP OSD 002—Family
Medicine: Report of a Regional Scientific
Working Group Meeting on Core Curriculum;
Colombo, Sri Lanka, 2003;9–13.
20. h t t p : / / w w w . i m a c g p i n d i a. c o m / i n d e x .
php?option=com_content&view=article&id=
64&Itemid=79 (Accessed on 27-09-2011)
21. http://www.natboard.edu.in/index.php
(Accessed on 27-09-2011).
22. Dr Zachariah P. Family medicine & medical
education reform. The Hindu-Tuesday, 2011.
23. Saultz JW, et al. Is it time for a 4-year family
medicine residency? Fam Med. 2004;36(5):
363–6.
24. Martin JC, et al. Future of Family Medicine
P ro j e c t L e a d e r s h i p C o m m i t t e e. A n n
Fam Med. 2004;2Suppl(1):S3–32. [PMID:
15080220:Abstract]
25. Showstack J, et al. Primary care: the next
renaissance. Ann Intern Med, 2003; 138(3):268–
72. [PMID: 12558378:Abstract].
26. McWhinney IR. Family Medicine in perspective.
N Engl J Med. 1975;293:176–81.
27. ROME IV: Report of a Regional Consultation,
New Delhi, India. 1993;5–10.
28. Bush J. Is it time to re-examine family practice?
Fam Pract Manag. 2001;8(8):43–8[PMID:
11574975:Abstract]
29. Goh Lee Gan, et al. Family Medicine
development in the Asia-Pacific region. The
Singapore Fam Phy, 2001;27(3):31–36.
 4 Definitions
“If you would converse with me, you must first define your terms”
Definitions are statements expressing the
essential nature, quality or scope of something;
they may state or distinguish boundaries of
one field from another. But in the discipline of
medical specialities, their clear demarcation is
difficult. Between one speciality and another,
there are invariably overlapping boundaries.
However, it’s more important to arrive at the
center of the discipline accurately, necessarily
accepting the overlap with other specialties.
The definition then is more likely to provide a
framework on which the professional skills and
the core contents of teaching, research, and
development can be more precisely applied.1
General Practice
The term general practitioner first came into
use around the year 1810,2 and first appeared
in The Lancet in 1823. 3 Since then many
definitions of General practice/Primary care/
Family Medicine have been proposed.
Leeuwenhorst Definition—19744
This is one of the most quoted definitions,
which states:
“The general practitioner is a licensed
medical graduate who gives personal, primary
and continuing care to individuals, families,
and a practice population, irrespective of age,
sex, and illness.
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—Voltaire.
It is the synthesis of these functions, which
is unique. He will attend his patients in his
consulting room and in their homes and
sometimes in a clinic or hospital.
His aim is to make early diagnoses. He will
include and integrate physical, psychological
and social factors in his consideration about
health and illness. This will be expressed in
the care of his patients.
He will make an initial decision about every
problem, which is presented to him as a doctor.
He will undertake the continuing management
of his patients with chronic, recurrent or
terminal illnesses.
Prolonged contact means that he can use
repeated opportunities togather information at
a pace appropriate to each patient and build
up a relationship of trust, which he can use
professionally.
He will practice in co-operation with other
colleagues medical, and non-medical.
He will know how and when to intervene
through treatment, prevention and education
to promote the health of his patients and their
families. He will recognize that he also has a
professional responsibility to the community.”
Changing Domain of General
Practice (Table 4.1)
Initially general practice was in its infancy
as a discipline, particularly with regard to its
 Chapter 4: Definitions 23
Table 4:1  Changing domain of general practice
•  The move from institutional care to domiciliary care or day care centres, e.g. care of the elderly and disabled
individuals at home and by Integrated Intermediate Care Team.
•  Changes in professional boundaries, e.g. trained nurses as home visitors, paramedics in emergency care,
family physicians in hospital management systems.
•  The development of primal care subspecialties, e.g. adolescent medicine, geriatric medicine, palliative
medicine, sport medicine.
•  Health promotion and disease prevention, e.g. in diseases such as HIV, cancer, stroke, diabetes, coronary
artery disease.
•  The development of consumerism and consumer protection act.
•  Wider acceptance of other primary healthcare providers, e.g. primary care nurse practitioners, community
psychiatric nurses.
•  New emphasis on cost containment and resource management.
•  The development of evidence based medicine and guidelines.
•  Information and communication technology.
•  The team concept to improve quality in general practice.
•  Development of Rural general Practitioners as a speciality.
•  Increasing competition from private sectors/organizations.
•  Remodeling of biomedical model/development of new health care models**

Ref. - Wade DT et al. Do biomedical models of illness make for good healthcare systems? BMJ. 2004 Dec 11;
329(7479):1398-401. [PMID: 15591570].

teaching and research base. However, the
following major changes have influenced the
contemporary general practice.
Demographic, cultural and industrial
evolution: In the past 40 years, reforms in health
care systems have taken place all over the world.
The changes in demography, culture, rapid
growth in industrialization, lifestyle, medical
advances in information and communication
technology, health economics, etc. demand
new ways of providing and delivering health
care to the community. Increased travel and
immigration of population have caused changes
in the distribution of health and diseases.
This presents a change in the epidemiology
of practice and new challenges for family
doctor. The family doctor needs a broader
understanding of culture, ethnic and religious
differences, and their impact on illness, health
and their implications for treatment.
Continuous medical education: Further, in
these days of consumerism and performance
management, there is an expectation that family
doctors maintain their skills through life-long
learning, and demonstrate them through quality
assurance. In some healthcare systems, this
has lead to compulsory reaccreditations on a
periodic basis. Van Wheel,5 in his recent lecture
to RCGP, Spring Meeting, emphasized the need
for academic development to enable transfer of
knowledge, expertize, and experience to develop
techniques and methodology addressing the
specific requirements of general/family practice,
and the need for common culture of teaching,
research, and training.
Patient autonomy: Over the years the
views of the society has also changed, and
there has been an increasing role for the
patient as a determining factor in health care
and its provision (i.e. patient autonomy). The
opinion of the clinician is no longer regarded
as sacrosanct and a new dialogue is emerging
between healthcare consumers and providers.
Richards JG, et al6 state, “The nature of General
Practice, and the environment within which
we operate, has altered immensely, but it
should be recognized that change for the sake
of change is often a mistake. It is appropriate
that we should step back and review what has
been happening to see whether it fits with
our perception of the role of General Practice
and how the community may best be served.

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 24  Section 1: Basic Principles
Perhaps we have moved too far and too fast, or
conversely we may not have moved far enough
or fast enough. Although we may be able to
influence the direction of future change, we
also have to accept that ultimately many of
the decisions about where we are going will be
made by others, often having entirely different
values and objectives from those that we hold
to be important. ” The future family doctor has
to be not only aware of this change, but be able
to thrive in such an environment.
Resource management : There is also
a developing role in relation to resource
management*. With the ever-increasing costs
of healthcare, the family doctors need to be
aware of their role in promoting cost effective
practice, not only in themselves but also to
their colleagues.
Therefore, in the context of evolving scenario
and rapid advances in many facets of general
practice, it is vital that the complex and essential
role of family doctors within the healthcare
systems is fully understood by medical
professionals, healthcare planners, economists,
politicians and the public. International evidence
indicates that health systems based on effective
primary care with highly trained family doctors
practicing in a community provides both
cost effective and clinically effective care;7, 8
and to effectively project and manage these
circumstances, new definitions of general
practice/family medicine have been proposed
by peer organizations or committees across the
world. The notable ones are:
Wonca Definition—1991 (World
Organization of Family Doctors)9
“The general practitioner/family physician
is the physician who is primarily responsible
for providing comprehensive care to every
*Resource management is the efficient and effective deployment of an organization's resources when they
are needed. Such resources may include human resources, financial resources, human skills, production
resources, information technology, etc.
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individual seeking medical care and arranging
for other health personnel to provide services
when necessary. The general practitioner/
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.
The general practitioner/family physician
cares for the individual in the context of
the family, and the family in the context
of the community, irrespective of race,
religion, culture or social class. He is clinically
competent to provide the greater part of
their care after taking into account their
cultural, socio-economic, and psychological
background. In addition he takes personal
responsibility for providing comprehensive
and continuing care for his patients.
The general practitioner/family physician
exercises his/her professional role by providing
care, either directly or through the services of
others according to their health needs and
resources available within the community he
or she serves.”
Olesen Definition—200010
Olesen et al. have stated that the original
Leeuwenhorst definition is out of date and
does not reflect the reality of family medicine
today. The dissatisfaction expressed by
Olesen et al is because many of those who
regard themselves as family doctors are
working in healthcare systems in which it is
not possible to comply with many features
of Leeuwenhorst definition; particularly the
concept of continuity and community setting.
They cite examples such as family doctors
working in emergency departments, pain
clinics, etc. as support to their viewpoint. They
have suggested the following definition:

“The general practitioner is a specialist
trained to work in the front line of a health care
system and to take the initial steps to provide
care for any health problem(s) that patients
may have.
The general practitioner takes care of
individuals in a society, irrespective of the
patient’s type of disease or other personal
and social characteristics, and organizes the
resources available in the health care system
to the best advantage of the patients.
The general practitioner engages with
autonomous individuals across the fields
of prevention, diagnosis, cure, care, and
palliation, using and integrating the sciences of
biomedicine, medical psychology, and medical
sociology.”
The two preceding definitions, i.e. those of
WONCA 1991, and Olesen 2000, still seem to
have their roots very much in the Leeuwenhorst
definition. The WONCA 1991 statement
appears to be more relevant to general
practice/family practice, and incorporates, as
has been described, some of its characteristic
features such as ‘generalist, comprehensive,
continuing, family focused, collaborative,
and community oriented’. In its clinical
decision making section it describes the early
presentation of undifferentiated problems,
and a large number of problems which do
not fit with standard biomedical diagnoses,
and the different prevalence of illness and
disease within the general practice setting as
compared with the secondary care setting.
The Olesen el al statement includes curative,
rehabilitative, and supportive care, and
provides a framework for research, teaching,
development, and resource management.
These statements emphasize the fact that
our education process must prepare family
doctors for very different clinical processes
*Revised in 2005 by a working party of EURACT Council led by Dr Justin Allen, on behalf of WONCA
European Council.
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Chapter 4: Definitions 25
which are not primarily mechanistic or
technical in nature, which is the way that
medicine is still predominantly taught in
medical schools throughout the world.
To meet the expanding demands on the
general practice curriculum in this evolving
environment, an authoritative statement
which defines both the discipline of general
practice/family medicine and the tasks of the
general practitioner, and relate them, at least
in general terms, to the context of the present
health care system, and a definition of the role
of family doctors with reference to the health
care system in which they work needs to be
formulated.
The European Definitions—2005*
(Wonca Europe Definitions—2005)11
From the discussion above it’s clear that
‘general practice’ is difficult to define because
of its nature of integrating knowledge and
skill from many disciplines. There is no
internationally consistent definition, and
the confusion between terms “medical
practitioners”, “general practitioners”, or
“family doctor” prevails. The term “family
physician” is used in some countries to
highlight the discipline as a speciality with
training. Therefore, in order to arrive at a
new and amicable definition of general
practice/family physician/family medicine,
the members of the 30 European countries
affiliated to WONCA EUROPE (The European
Society of general practice or family medicine;
The Regional Organization of the World
Organization of family doctors – WONCA)
deliberated at the workshop 2001, WONCA
Europe conference in Tampere, Finland,
wherein a substantial majority felt there should
be a new definition, and it should encompass a
description of both the task and the principles
 26  Section 1: Basic Principles
of the discipline (Table 4.1). A draft statement
was agreed for consultation more widely. This
was carried out by WONCA Europe, which
sent the papers for comment to all European
colleges and National Associations, and other
organizations involved in Family Medicine
in Europe. The responses were collected
and presented to a conference of these
organizations in Noordwijk. The Netherlands,
in March 2002, following which the draft was
finalized. The consensus statements arrived at
the conference, with respect to the “Discipline
of General Practice/Family Medicine”, and the
“Specialty of Family Medicine” is as follows:
The European Definition of the Discip­
line of General Practice/Family Medicine
“General Practice/Family medicine is an
academic and scientific discipline and a
clinical speciality with its own educational
content, research, and evidence base and
clinical activity, orientated to primary care.”
The European Definition of the Specialty
of General Practice/Family Medicine
“General Practitioners/family doctors are
specialist physicians trained in the principles
of the discipline. They are personal doctors,
primarily responsible for the provision of
comprehensive and continuing care to every
individual seeking medical care irrespective of
age, sex and illness. They care for individuals
in the context of their family, their community,
and their culture, always respecting the
autonomy of their patients. They recognize they
will also have a professional responsibility to
their community. In negotiating management
plans with their patients they integrate
physical, psychological, social, cultural and
existential factors, utilizing the knowledge
and trust engendered by repeated contacts.
General Practitioners/family physicians
exercise their professional role by promoting
health, preventing disease, and providing cure,
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care, or palliation. This is done either directly,
or through the services of others according
to the health needs and resources available
within the community they serve, assisting
patients where necessary in accessing these
services. They must take the responsibility
for developing and maintaining their skills,
personal balance and values as a basis for
effective and safe health care.”
The European definition outlines eleven
“characteristics” of the Discipline of General
Practice/Family Medicine that in turn can
be subdivided into six “core competencies”.
For the purpose of clarity the committee has
used the following definitions to clarify what
is meant by each of these terms:
™™ “Characteristic” can be defined as a
distinctive ability which every general
practitioner should master.
™™ “Core” means essential to the discipline.
™™ “Competence” relates to specific tasks
that a general practitioner should be able
to perform.
Characteristics: The Characteristics
of the Discipline of General Practice/
Family Medicine are that it:
™™ Is normally the point of first medical contact
within the healthcare system, providing
open and unlimited access to its users,
dealing with all health problems, regardless
of the age, sex, or any other characteristic of
the person concerned.
“Normally” is used to indicate that in some
circumstances, e.g. major trauma, it is not
the first point of contact. However it should
be the point of first contact in most other
situations. There should be no barriers to
access, and family doctors should deal with
all types of patient, young or old, male or
female, and their health problems. General
practice covers a large field of activities
determined by the needs and wants of
patients. This outlook gives rise to many

facets of the discipline and the opportunity
of their use in the management of individual
and community problems.
™™ Makes efficient use of health care resources
through co-coordinating care, working
with other professionals in the primary care
setting, and by managing the interface with
other specialties, and taking an advocacy
role for the patient when needed.
This “coordinating” role is a key
feature of the cost effectiveness of good
quality primary care ensuring that
patients see the most appropriate health
care professional for their particular
problem. The synthesis of the different
care providers, the appropriate distribution
of information, and the arrangements for
ordering treatments rely on the existence
of a coordinating unit. Developing team
work around the patient with all health
professionals will benefit the quality of
care. By managing the interface with other
specialties the discipline ensures that
those requiring high technology services
based on secondary care can access them
appropriately. A key role for the discipline
is to provide advocacy, protecting patients
from the harm, which may ensue through
unnecessary screening, testing, and
treatment, and also guiding them through
the complexities of the healthcare system.
™™ Develops a person-centered approach,
orientated to the individual, his or her
family, and their community.
Family medicine deals with people as
living human beings and advises a humane
approach to them. The starting point of the
process is the patient. It is as important to
understand how the patients cope with
and view their illness as dealing with
the disease process itself. The common
denominator is the person with his/her
beliefs, fears, expectations and needs.
*Ref. Chapter 10: Communication skills, p. no. 87.
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Chapter 4: Definitions 27
™™ Has a unique consultation process, which
establishes a relationship over time, through
effective communication between doctor
and patient.
Each contact between patient and their
family doctor contributes to an evolving
story, and each individual consultation
can draw on this prior shared experience.
The value of this personal relationship
is determined by the communication
skills* of the family doctor and is in itself
therapeutic.
™™ Is resp onsible f or the provision of
longitudinal continuit y of care as
determined by the needs of the patient.
The approach of general practice must
be constant from birth (and sometimes
before) until death (and sometimes
afterwards). It ensures the continuity
of care by following patients through
substantial periods of their lives and
through many episodes of illness. They
are also responsible for ensuring that
healthcare is provided continuously, and
also coordinating such care with other
specialities when they are unable to
provide it personally.
™™ Has a specific decision making process
determined by the prevalence and incidence
of illness in the community.
Problems are presented to family
doctors in the community in a very different
way from their presentations in secondary
care, i.e. the prevalence and incidence of
illnesses is different in general practice
from that which appears in a hospital
setting, and serious diseases present
less frequently in general practice than
in hospital. Therefore, decision-making
process and the predictive value, i.e. the
positive or negative value of a clinical
sign or of a diagnostic test have a different
 28  Section 1: Basic Principles
weight in family medicine as compared to
the hospital setting.
™™ Manages simultaneously both acute and chro­
nic health problems of individual patients.
Family medicine must deal with all of the
health care problems of the individual patient.
It cannot limit itself to the management of the
presenting illness alone, and often the doctor
will have to manage multiple problems. The
patient often consults for several complaints
and these complaints multiply with age.
The simultaneous response to several
demands renders necessary a hierarchical
management of the problems which takes
account of both the patient’s and the doctor’s
priorities.
™™ Manages illness, which presents in an
undifferentiated way at an early stage in
its development, which may require urgent
intervention.
The patient often comes at the onset of
symptoms, and it is difficult to make a
diagnosis of a certain disease or illness
when the symptoms are still evolving.
This manner of presentation means that
important decisions for patients have to be
taken on the basis of limited information and
the predictive value of clinical examination
and tests is less certain. Even if the signs of a
particular disease are generally well-known,
this does not apply for the early signs, which
are often non-specific and common to a
many diseases. Risk management under
these circumstances is a key feature of the
discipline. Having excluded an immediately
serious outcome, the decision may well be to
await further developments and review later.
™™ Promotes health and well-being both by
appropriate and effective intervention.
Interventions must be appropriate,
effective and based on sound evidence
whenever possible. Intervention when
*Advocacy: Described as “helping the patient take an active part in the clinical decision-making process
and working with the government and other authorities to maximize equitable distribution of services to
all members of society”.
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none is required may cause harm, and
wastes valuable health care resources.
™™ Has a specific responsibility for the health
of the community.
The discipline recognizes that it has a
responsibility both to the individual patient
and to the wider community in dealing with
health care issues. On occasions this may
lead to conflicts of interest, which must be
appropriately managed.
™™ Deals with health problems in their
physical, psychological, social, cultural
and existential dimensions.
The discipline has to recognize all these
dimensions simultaneously and give
appropriate weight to each. Illness behavior
and patterns of disease are varied by many
of these issues and much unhappiness
is caused by interventions which do not
address the root cause of the problem for
the patient.
The Core Competencies of the General
Practitioner/Family Doctor
The European definition of the discipline of
general practice has six core competencies:
™™ Primary care management includes (1
and 2 above) the ability:
ƒƒ To manage primary contact with patients,
dealing with unselected problems
ƒƒ To cover the full range of health conditions
ƒƒ To co-ordinate care with other pro­
fessionals in primary care and with
other specialists
ƒƒ To master effective and appropriate care
provision and health service utilization
ƒƒ To make available to the patient the
appropriate services within the health
care system, and
ƒƒ To act as advocate for the patient, i.e.
advocacy.*

™™ Person-centered care includes (3, 4, and
5 above) the ability:
ƒƒ To adopt a person-centered approach in
dealing with patients and problems in
the context of patient’s circumstances,
ƒƒ To apply the general practice con­
sultation to bring about an effective
doctor-patient relationship, with
respect for the patient’s autonomy,
ƒƒ To communicate, set priorities and act
in partnership, and
ƒƒ To provide longitudinal continuity of
care as determined by the needs of the
patient, referring to continuing and co-
coordinated care management.
™™ Specific problem solving skills includes
(6 and 7 above) the ability:
ƒƒ To relate specific decision-making
processes to the prevalence and
incidence of illness in the community,
ƒƒ To selectively gather and interpret infor­
mation from history-taking, physical
examination, and investigations, and
apply it to an appropriate management
plan in collaboration with the patient,
ƒƒ To a d o p t a p p ro p r i a t e w o rk i n g
principles, e.g. incremental investi­
gation, using time as a tool and to
tolerate uncertainty
ƒƒ To intervene urgently when necessary,
ƒƒ To manage conditions which may present
early and in an undifferentiated way, and
ƒƒ To make effective and efficient use
of diagnostic and therapeutic inter­
ventions.
™™ Comprehensive approach includes (8 and
9 above) the ability:
ƒƒ To manage simultaneously multiple
complaints and pathologies, both acute
and chronic health problems in the
individual,
*The Oxford Companion to Medicine defines holistic medicine as: "a discipline of preventive and
therapeutic medicine which emphasizes the importance of regarding the individual as a whole being
integral with his social, cultural, and environmental context rather than as a patient with isolated
malfunction of a particular system or organs".
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Chapter 4: Definitions 29
ƒƒ To promote health and well being by
applying health promotion and disease
prevention strategies appropriately, and
ƒƒ To manage and co-ordinate health
promotion, prevention, cure, care and
palliation and rehabilitation.
™™ Community orientation includes (10
above) the ability:
ƒƒ To reconcile the health needs of
individual patients and the health
needs of the community in which they
live in balance with available resources.
™™ Holistic* modeling includes (11 above)
the ability:
ƒƒ To use a bio-psycho-social model
taking into account cultural and
existential dimensions.
There are many similarities between the
statements of the principles which define
general practice/family medicine, but there
are also significant differences, which may be
due to differences in which the statements are
interpreted. Although none of these definitions
per se encompass all the key features of the
discipline, the statements have provided
an authentic view on what family doctors
should be providing in a way of services to the
patients, in order that patient care is of highest
quality and also cost effective so that family
medicine will develop to meet the health care
needs of the population of 21st century.
Definition of General Practitioner
A general practitioner is a registered medical
practitioner who is qualified and competent
for general practice. A general practitioner:
™™ Has the skills and experience to provide
whole person, comprehensive, coordinated
and continuing medical care; and
™™ Maintains professional competence for
general practice.
 30  Section 1: Basic Principles
Definition of Family Physician ™™ The ability to support children during
growth and development and during the
A family physician is a generalist who
adjustments to family and society.
takes professional responsibility for the
™™ A curious and consistently inquisitive
comprehensive care of unselected patients
attitude, enthusiasm for the undifferenti­
with undifferentiated problems, committed
ate d m e d i ca l p ro b l e m s a n d t h e i r
to the person regardless of age, gender, illness,
resolutions; an interest in the broad
organ system affected, or methods used.
spectrum of clinical medicine; the ability to
The American Academy of Family Physicians
deal comfortably with multiple problems
defines the family physician as12
occurring simultaneously in one patient;
“A physician who is educated and trained
and a desire for frequent and varied
in family practice—a broadly encompassing
intellectual and technical challenges.
medical specialty. Family physicians possess
™™ The family physician should be an effective
unique attitudes, skills and knowledge
coordinator in the appropriate use of
which qualify them to provide continuing
specialists, health services and community
and comprehensive medical care, health
resources. As Dr. Francis Peabody describes,
maintenance and preventive services to each
“A new demand has arisen—not for men who
member of the family regardless of age, sex or
are experts along narrow lines but for men
type of problem—be it biological, behavioral
who are in touch with many lines.”
or social. These specialists, because of their
™™ One of the foremost skills in family practice
background and interactions with the family,
is the ability to effectively utilize the
are best qualified to serve as each patient’s
knowledge of interpersonal relations in the
advocates in all health-related matters,
management of patients.
including the appropriate use of consultants,
™™ The family physician recognizes the effects
health services and community resources.”
that spiritual, intellectual, emotional and
Attributes of a Family Physician social factors have on patient’s illness; as
Sir William Osler quoted, “It is much more
™™ A strong sense of responsibility for the
important to know what sort of patient
total, ongoing care of individual and the
has a disease than what sort of disease a
family members during health, illness,
patient has.”
or rehabilitation. The patients consider a
good physician who:
Nine Principles that
ƒƒ Express genuine interest in them,
Define the Discipline
ƒƒ Thoroughly evaluates their problem,
McWhinney13 identifies nine principles that
ƒƒ Demonstrates compassion, under­
govern actions and define the discipline, and
standing and warmth, as every physical
taken together redefine a distinctive world
problem has an emotional component,
view. Family physicians:
which can be extremely significant,
™™ Are committed to the person rather than
ƒƒ Provides clear insight into what is to a particular body of knowledge, group
wrong and what must be done to of diseases, or special technique.
correct it, ™™ Seek to understand the context of the illness.
ƒƒ A high degree of intellectual honesty, ™™ See every contact with their patient as
and an opportunity for prevention or health
ƒƒ A clean sense of humor. education.

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™™ View the patients in their practice as a
population at risk.
™™ See themselves as part of a community-
wide network of supportive and healthcare
agencies.
™™ Should ideally share the same habitat as
their patients.
™™ See patients in their homes.
™™ Attach importance to the subjective
aspects of medicine.
™™ Manage resources.
Family Practice
Family practice is the professional discipline
that trains and sustains the doctors who
practice the evolving arts and sciences of
family medicine. Family practice is patient
centered, evidence based, family focused, and
problem oriented. It shares historical roots and
a worldwide movement with general practice.
Family medicine is the academic discipline
that both serves and leads the specialty of
family practice.
Difference—Family Practice and
General Practice
Although family practice follows the general
practice tradition, it has major differences
from general practice because the training
in family practice is broader. Family practice
residencies were developed in response to
a perceived need by the public, the medical
profession, and the government for well-
trained generalists. In addition to receiving
broad hospital training, family practice
residents receive extensive training in
comprehensive and continuous outpatient
medicine for persons of all ages. As a specialty,
family practice has stringent requirements
for continuing medical education, board
certification and recertification periodically.14
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Chapter 4: Definitions 31
At present, given the differences in the
way these terms are used and interpreted
in different countries, the terms general
practitioner and family physician refer to
the medical practitioner who has completed
specific postgraduate training, analogous
to that of other medical specialities, in the
discipline of general practice or family
medicine. Correspondingly, the terms general
practice, general practitioner family medicine,
and family physician are used as being
equivalent.16,10 However, it’s to be noted that,
although general practitioners and family
doctors evolve from the best of traditional
general practice, they are differentiated from
their former counterparts by being trained
specifically for their roles.
Advantages of Family Practice
™™ Primary health care is a cost effective
care, which involves a single personal
physician who ensures the most logical and
economical management of a problem.
™™ Fa m i l i e s w h o a re u n d e r a f a m i l y
physician’s care have a fewer incidences
of hospitalizations, fewer operations, and
fewer visits for illnesses.
™™ House calls, which is an important part of
family practice is a valuable tool to develop
a thorough understanding of the patients
and their environment. It is also a valuable
tool for visiting the elderly immobile
person at home.
™™ The family physician can join a group
practice or individually practice. The
advantages of joining a group practice are:
ƒƒ Partnership
ƒƒ Opportunity to share house calls
ƒƒ Spending more time with their families
ƒƒ More time to remain current with
medical advances through CME
programs, and
ƒƒ Financial advantage.
 32  Section 1: Basic Principles
Primary Care
What is primary care? 15
The following five definitions relating to
primary care describe the care provided to
the patient, the system of providing such
care, the types of physicians* whose role in
the system is to provide primary care, and the
role of other physicians, and non-physicians
in providing such care. Taken together they
form a framework within which patients will
have access to efficient and effective primary
care services of the highest quality.
Definition
Primary Care
Primary care is that care provided by
physicians specifically trained for and skilled in
comprehensive, first contact, and continuing
care for persons with any undiagnosed
sign, symptom, or health concern (i.e. the
undifferentiated patient), not limited by
problem of origin (biological, behavioral, or
social), organ system, or diagnosis.
Primary care includes health promotion,
disease prevention, health maintenance,
counseling, patient education, diagnosis and
treatment of acute and chronic illnesses in
a variety of health care settings (e.g. Office,
inpatient, critical care, long-term care, home
care, day care, etc.). Primary care is performed
and managed by a personal physician often
collaborating with other health professionals,
and utilizing consultation or referral as
appropriate.
Primary care provides patient advocacy
in the healthcare system to accomplish cost-
effective care by coordination of health care
services. Primary care promotes effective
communication with patients and encourages
the role of the patient as a partner in health
care.
*In this document, the term physician refers only to doctors of medicine (MD) and osteopathy (DO).
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Primary Care Practice
A primary care practice serves as the patient's
first point of entry into the healthcare system,
and as the continuing focal point for all needed
health care services. Primary care practices
provide patients with ready access to their
own personal physician or to an established
back-up physician when the primary physician
is not available.
Primary care practices provide health
promotion, disease prevention, health
maintenance, counseling, patient education,
diagnosis and treatment of acute and chronic
illnesses in a variety of health care settings (e.g.
office, inpatient, critical care, long-term care,
home care, day care, etc.).
Primary care practices are organized to
meet the needs of patients with undifferentiated
problems, w ith the vast maj or it y of
patients’concerns and needs being cared for
in the primary care practice itself. Primary
care practices are generally located in the
community of the patients, thereby facilitating
access to health care while maintaining a
wide variety of speciality and institutional
consultative and referral relationships for
specific care needs. The structure of the primary
care practice may include a team of physicians
and non-physician health professionals.
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 patient's care. Such a physician
must be specifically trained to provide primary
care services.
Primary care physicians devote the majority
of their practice to providing primary care
services to a defined population of patients. The
style of primary care practice is such that the
personal primary care physician serves as the

entry point for substantially all of the patient's
medical and health care needs—not limited
by problem origin, organ system, or diagnosis.
Primary care physicians are advocates for the
patient in coordinating the use of the entire
health care system to benefit the patient.
Non-primary Care Physicians Providing
Primary Care Services
Physicians who are not trained in the primary
care specialties of family medicine, general
internal medicine, or general pediatrics may
sometimes provide patient care services
that are usually delivered by primary care
physicians. These physicians may focus
on specific patient care needs related to
prevention, health maintenance, acute
care, chronic care or rehabilitation. These
physicians, however, do not offer these
services within the context of comprehensive,
first contact and continuing care.
The contributions of physicians who deliver
some services usually found within the scope
of primary care practice may be important to
specific patient needs. However, the absence
of a full scope of training in primary care
requires that these individuals work in close
consultation with fully-trained, primary care
physicians. An effective system of primary care
may utilize these physicians as members of the
health care team with a primary care physician
maintaining responsibility for the function of
the healthcare team and the comprehensive,
ongoing healthcare of the patient.
Non-physician Primary Care Providers
There are providers of health care other than
physicians who render some primary care
services. Such providers may include nurse
practitioners, physician assistants, and some
other healthcare providers.
These providers of primary care may meet
the needs of specific patients. They should
provide these services in collaborative teams
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Chapter 4: Definitions 33
in which the ultimate responsibility for the
patient resides with the primary care physician
(1975, 2006).
Use of Term
The American Academy of Family Physicians
recognizes the term primary care and those
family physicians provide services commonly
recognized as primary care. However, the
terms, "primary care" and "family practice"
are not interchangeable. Primary care does
not fully describe the activities of family
physicians or the practice of family medicine. 
Similarly, primary care departments do not
replace the form or function of family medicine
departments (1977, 2006).
How does Primary Care Differ from
Other Levels of Health Care?16
In addition to primary care, health care
systems provide other levels of care including
emergency care and speciality care. These
other types of care can be distinguished
from primary care by several structural and
process characteristics, although in practice
their respective boundaries are not always
distinguishable. The Table 4.2 summarizes
how key features of primary care relate to other
levels of care within a healthcare system.
Is Primary Care the Same as
Ambulatory (Mobile) Care?12
Primary care and ambulatory care are not the
same. Not all primary care is ambulatory care,
and not all ambulatory care is primary care. To
illustrate, a primary care provider's responsibility
for coordination does not end when a patient
leaves the ambulatory care setting and is
hospitalized. Similarly, a procedure performed
by a specialist in an ambulatory care setting is
not considered primary care, nor is the ongoing
ambulatory care of, e.g. complicated cancer
being managed by a specialist.
 34  Section 1: Basic Principles
Table 4.2  Key features of primary care
Level of care First-contact Continuity
Primary care Yes Yes
Emergency care Yes No
Specialty care No S o m e t i m e s . F o r No
patients with certain
medical conditions,
continuity might be
a feature of specialty
care
The identifying characteristic of ambulatory
care is the site in which it's delivered. Ambulatory
care is care provided in all settings except hospital
inpatient and other institutional settings.
Ambulatory care can be delivered in physician
offices, hospital or freestanding outpatient
diagnostic and surgical centers, urgent care
centers, outpatient rehabilitation centers,
outpatient drug and alcohol rehabilitation
centers, homes, and hospices.
Advances in diagnostic, therapeutic and
rehabilitative services due to technological
and pharmaceutical breakthroughs have
shifted many specific health care services from
inpatient to ambulatory or outpatient settings.
Payer and consumer-driven factors, such as
cost-containment and convenience, also have
influenced the growth of ambulatory services
in recent years. These ambulatory care trends,
both technologically and economically based,
are expected to continue and even accelerate
in the years ahead.
Is Primary Care the Same as Managed
Care?12
Primary care and managed care are not
the same. Primary care is an approach to
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Comprehensiveness Coordination
Yes Yes, primary care provider
assumes responsibility for
overall coordination
No Emergency care provider
facilitates coordination by
supplying information on
encounter to primary care
provider
Specialty care provider
facilitates coordination by
supplying information on
encounter to primary care
provider. For patients with
certain medical conditions,
specialty care provider might
assume responsibility for
overall coordination
provide care to patients and managed care
is a strategy to finance services, which may
be defined as “any system of health payment
or delivery arrangements, where the health
plan consisting of defined system of selected
health care providers, attempts to control
or coordinate use of health services by its
enrolled members in order to contain health
expenditures, improve quality, or both.
Enrollees have a financial incentive to use
participating providers that agree to furnish a
broad range of services to them.”
Primary care providers are comparable to
managed care's case-managers in the sense
that both coordinate care as well as directly
provide it to the majority. Managed care is not
necessarily based on a primary care model.
Managed care often does not place priority
on maintaining continuity of the primary care
practitioner over time or assuring services are
sufficiently comprehensive to cover all health
care needs of patients. Moreover, managed
care is increasingly used for care of particular
types of conditions (such as managed mental
health care), whereas primary care is, by
definition, care of patients regardless of what
particular types of problem they have.

The growth of managed care in recent
years is largely attributed to the drive for
cost-containment and/or the pursuit of value
in health care. Managed care seeks to create
financial incentives for providers and/or
patients to limit unnecessary utilization of
services. Primary care, in contrast, is a concept
that is independent of financial incentives,
although primary care oriented healthcare
systems have been shown to cost less than
specialty oriented healthcare systems.
Managed care is a broad term encompassing
a diverse mix of health plans and systems. The
major types of managed care plans are:
™™ Health maintenance organizations (i.e.
HMOs)
™™ Preferred provider organizations (i.e.
PPOs)
™™ Point-of-service (i.e. POS) plans.
Role of Primary Care Provider
in Common Managed Care
Arrangements12
™™ Health maintenance organizations
(HMOs). This highly structured managed
care plan requires formal enrollment with
a primary care provider in the network.
HMOs include staff models, group models
and independent practice associations. A
referral from the primary care provider is
required for all care. If an enrollee chooses
to seek care outside the HMO, he or she
typically must bear the entire cost for the
out-of-network care.
™™ Preferred provider organizations (PPOs).
A PPO is a type of managed care plan that
offers financial incentives to enrollees
to seek care from a designated group
of providers—typically physicians,
hospitals and labs—that have agreed to
furnish services to a specified population
at a reduced charge. In return for the
discounted charges, the providers expect
to experience growth in the size of their
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Chapter 4: Definitions 35
patient population. Criteria often used by
plans in selecting providers to participate
in a PPO are level of discount, patient
satisfaction and cost-effective utilization
practices. Enrollees can opt to obtain care
from this select group of providers or can
go to providers not on the PPO list. Formal
enrollment with a primary care provider is
not a feature of PPOs and the plan does not
require referrals for visits inside or outside
the PPO. In this way PPOs resemble fee-for-
service plans. Enrollees pay more out-of-
pocket for using a provider not on the list.
™™ Point-of-service (POS) plans. This recent
entry into the managed care world—the
POS plan—require formal enrollment with
a primary care provider, but the enrollment
is loosely structured and subscribers are
free to use providers inside or outside
of the network on any given day, or at
any point-of-service. POS plans attempt
to balance payers' demands for cost-
containment with enrollees' demands for
freedom of choice of providers. POS plans
are sometimes referred to as open-ended
HMOs. A referral from the primary care
provider is not required for out-of-network
visits but is required for in-network care.
Enrollees pay more out-of-pocket for using
a provider outside the network.
Although managed care may be organized
with a solid primary care infrastructure,
managed care arrangements can exist without
being grounded in a primary care model. PPOs
are evidence of this.
Similarly, primary care—the provision of
accessible, continuous, comprehensive and
coordinated care—certainly can exist in the
absence of managed care. This is evidenced
by the many primary care providers who
are not in an HMO or POS plan and are not
subject to any financial incentives to limit
appropriate utilization, but do actively manage
and coordinate care across the continuum for
their patient population.
 36  Section 1: Basic Principles
Table 4.3  English language definitions

General practitioner/ Synonyms, used to describe those doctors who have undergone postgraduate training
Family doctor or family in general practice/family medicine at least to the level defined by Medical board.
physician
Primary care physician A physician from whatever discipline working in a primary care setting.
Secondary care A physician who has undergone a period of higher postgraduate training in an organ/
physician disease based discipline, and who works predominately in that discipline in a hospital
setting.
Specialist A physician from whatever discipline who has undergone a period of higher
postgraduate training.
Primary care The settings within a healthcare system, usually in the patient’s own community, in
which the first contact with a health professional occurs (excluding major trauma).

English Language Definitions20 8. Jane Doherty, Riona Govender. Disease Control

There is a lot of confusion regarding both
the language used about general practice or
family medicine and its interpretation. In
order that there can be no misinterpretations
or misunderstandings for the purposes of
these discussion papers the following terms
are defined in Table 4.3.
References
1. Olesen F, et al. General practice—time for
a new definition. BMJ, 2000;320(7231):354–
7[PMID: 10657333: Free full text].
2. Louden ISL. The origin of gen. pract., J Royal
Coll Gen Pract. 1983;33:13–18.
3. Leavesley J. a history of gen. pract., Med J Aust.
1984;107–9.
4. Leeuwenhorst. The gen pract. In Europe-
European conf. on teaching of gen. pract. 1974;
Netherlands.
5. Van Wheel C. The impact of science on future
of medicine: RCGP Spring Meeting. 2001.
6. Richards JG, et al. General Practice in New
Zealand. Published by The Royal New Zealand
College of General Practitioners, 88 The
Terrace, Wellington, New Zealand. 1997.
7. David Haslam. President, Royal College of
General Practitioners, London. UK. Guest
Editorial: The best of both worlds - How
primary care can save lives and money. Malta
Med J. 2008;20(1).
Priority Projects (The World Bank and WHO)
Working Paper No. 37. The Cost-effectiveness of
Primary care Services in Developing Countries:
A Review of the International Literature. 2004.
9. The role of gp/fp in the health care systems – a
statement from WONCA. 1991.
10. Olesen F., et al. gen. pract.—Time for a new
definition. BMJ. 2000;320:354–7.
11. The European definition of gen. pract./fam.
Med. , WONCA Europe. 2002 ; Barcelona, Spain
12. American Academy of Fam. Phy., 1999–2000.
AAFP Reference Manual : Selected topics on
health issues, Leewood ; AAFP, 1999.
13. McWhinney IRA. Text Book of Fam. Med. , 2nd
ed., Oxford univ. press. 1997.
14. Framework for professional admistrative
devolpment of Gen Pract/Fam. Med. In
Europe; WHO, Regional off. For Europe.
15. American Academy of Fam. Phy. Primary Care
Reinvestment Act of 2004, AAFP Legislative
Stance. Web site:
http://www.aafp.org/online/en/home/policy/
policies/p/primarycare.html. Accessed on 31-
01-09.
16. Primary care in VA. Barbara Starfield, et al.
Boston: Management decisions and research
center; Washington, DC: U S depart. of
Veterans Affairs. Office of Research and
Development. Health Services Research and
Development Service, 1995.
17. Lamberts H. Internationnal clasiffcation of
primary care (ICPC): Oxford Univ. Press,
Oxford : Oxford Univ. Press ; 1987

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 5 THE “Family”
IN FAMILY MEDICINE

“To put the world right in order, we must first put the nation in order;
to put the nation in order, we must first put the family in order; to put the family in
order, we must first cultivate our personal life; we must first set our hearts right.
—Conficus

Focus on Family Health Care
Family health care (FHC) may be defined as an
art and science of providing comprehensive
health care to the family as a whole for the
purpose of prevention of diseases, prolonging
life, promoting health and efficiency of family
through organized family efforts. As such FHC
encompasses the physical, mental, social,
psychological and religious well-being of
members of all age groups and their freedom
from “infirmity”. FHC envisages not only
absence of disease but also positive health of
all family members. Absence of disease is an
indication toward a healthy family.
The reason for FHC presently gaining
dominance because it significantly involves
and deals principally with the inherent
“biological and social unit” which facilitates
achievement of optimum healthcare. No
other medical specialty has a family focus
or uses a family-oriented approach. A large
body of research has demonstrated that health
problems can be managed more successfully
by dealing with the family system than by
limiting one’s approach to the individual’s
illness.1, 2
It has long been recognized that the status
of an individual’s health has often its origin in
his/her family health. Families are the primary
context within which most health problems
and illnesses occur and have a powerful
influence on health outcomes. 3 Further,
family interventions have been shown to
improve health outcomes for a variety of health
problems.4 As James Dennis has written—“it is
the family milieu, and very early in life, that we
find the genesis of social, anti-social human
behavior; mental health and illness; many
communicable diseases and many nutritional
or other factors that ultimately lead to many
chronic degenerative and disability disorders
of later life. It is not possible to separate poor
mental and physical health, ignorance and
poverty from the pathology of the family.”5
Family—Definition
Family is a group of individuals united by
the ties of marriage, blood or adoption; and
usually representing a single household. The
family may be extended vertically to include
other generations, such as grandparents, and
horizontally to include other relatives such
as brothers and sisters. McDaniel et al define
family as, “Any group of people related either
biologically, emotionally, or legally.” 6 This
includes all forms of traditional and non-
traditional families such as unmarried couples,
blended families, and gay and lesbian families.

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 38  Section 1: Basic Principles
The family, as an institution, provides
for the rearing and socialization of children,
the care of the aged, sick or disabled, the
legitimation of procreation, and the regulation
of sexual conduct in addition to supplying
basic physical, economic, and emotional
security for its members.
The United Nations refer to the family as
the basic unit of the society; it is appreciated
for the important socio-economic functions
that it performs. In spite of the many changes in
society that have altered its role and functions, it
continues to provide the natural framework for
the emotional, financial, and material support
essential to the growth and development of its
members, particularly infants and children, and
for the care of other dependents, including the
elderly, disabled and infirm. The family remains
a vital means of preserving and transmitting
cultural values. In the broader sense, it can, and
often does, educate, train, motivate and support
the individual member, thereby investing in their
future growth and acting as a vital resource for
development.7
The members of the family are inextricably
joined together by social and individual factors
such as love, affection, mutually supporting,
inter-dependent, complementary in function,
consistent in their family obligations. While its
members share a long history, which carries
with it varied genetic, economic, social,
religious and cultural influences, the family
unit itself serves to help integrate each of its
members into the community and the wider
society; while at the same time addressing
itself to the material as well as the emotional,
cultural, social, and sexual and physical needs
of its members. The family offers each member
nurturance, which permits psychosocial
growth and development, creates a sense of
historical perspective and provides a base
from which the process of social definition
begins. Thus “Family” is a social organization,
which is based on strong tradition, culture and
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rich heritage. Family represents an informally
managed group of members whose behavior,
action, and contribution are governed by
“unwritten rules”, carried through generations.
Characteristics of a Healthy Family
Successful families have certain characteristics,
and their understanding gives the family doctor
a basis for assessing the health of the family and
a goal to help set targets for change in disrupted
families. Such characteristics are:8
™™ Healthy communication—Family members
have freedom of expression for their
feelings and emotions. Family members
talk with one another and listen well to
what others are trying to say through their
words, expressions, and actions.
™™ Personal autonomy—It includes appropri­
ate use of power sharing between spouses.
Families decide how responsibilities will be
divided among family members.
™™ Flexibility—There is appropriate “give and
take” with adaptation to individual needs
and changing family circumstances.
™™ Appreciation—This involves encourage­
ment and praise so that members develop
a healthy sense of self-esteem. Families
function best when the individuality of
each family member is acknowledged and
appreciated.
™™ Support networks—Adequate support,
especially emotional support, from
within and without the family engenders
security, resistance to stress and a healthy
environment in general. The family
physician is part of this network.
™™ Family time and involvement—Studies have
shown that the most satisfying hallmark of a
happy family is “doing things together”.
™™ Spouse bonding—The importance of a
sound marital relationship is obvious.
Their relationship is meaningful and
harmonious with each other. They are the
most important role models in the family.
 Chapter 5: The “Family” in Family Medicine 39
™™ Growth—Appropriate opportunities for
growth of individual family members are
essential. Their needs are fulfilled so that
they achieve most of their individual goals.
™™ Spiritual and religious values—An
attachment to spiritual beliefs and values
is known to be associated with positive
family health, supporting the saying, “The
family that prays together stays together.”
Pratt 9 has identified six healthy characteristics
of family:
™™ Members facilitate an interaction process,
™™ Members enhance individual development,
™™ Role relationships are structured effectively,
™™ Members actively attempt to cope with
problems,
™™ Members promote healthy home environ­
ments and lifestyle, and
™™ Members establish regular links with the
broader community.
Characteristics of a Disturbed
Family7
The following presentations may be indicators
that all is not well in the family, and so the
doctor needs to “think family”:
™™ Marital or sexual difficulties
™™ Multiple consultations of a family member—
being labeled as “thick file syndrome”, or
“difficult patient”
™™ Multiple consultations by multiple family
members
™™ Abnormal behavior in a child
™™ Inappropriate behavior in the antenatal
and/or postpartum period
™™ Drug or alcohol abuse in a family member
™™ Evidence of physical or sexual abuse in
wife or child
™™ Psychiatric disorders
™™ Increased susceptibility to illness, stress,
or anxiety.
*While the life-cycle approach alerts us to the necessity of change, it gives an impression that all the families
follow the same stages. In the real world this is clearly not the case, e.g. people get married after having
children, or not at all.
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It is important that the family physician
remain alert to the diversity of presentations
and takes the responsibility for identifying an
underlying family-based problem.
The Family Life Cycle and Role of
Family Physician
Family life cycle denotes the span of time from
the beginning of a family with marriage of a
young couple, the bearing, rearing and raising
their children, through the time when they
are again alone together until retirement and
inevitable death of one or both of the couple. It
consists of set of predictable steps or patterns
and developmental tasks families experience
over time. It begins with the marital union of
a couple, expands through the birth of their
children. Children grow, become independent,
and start their own family. The couple gets older
and finally the family disintegrates through the
death of the couple. As Neighbor RH befittingly
states, “The phrase family life-cycle implies the
symbol of a circle, the wheel of life, things going
round endlessly. But the image of motion in a
circle leaves out the important dimension of
development over a period of time...they seem
biologically or socially pre-ordained, in that
each can be varied or curtailed, but omission
of any one causes the death or disfigurement
of family life as we know it.”10
Neighbor RH 9 has described the seven
traditional phases in a typical family life-cycle
that are recognized as shown in the Table 5.1
Duvall et al11 have described eight definable
stages of development in a family cycle.
Understanding the implications of each stage
is necessary for the family doctor as it helps in
the formation of appropriate hypothesis about
the problem the individual is experiencing at a
particular stage and therefore to tailor a suitable
solution to the specific problem.*
 40  Section 1: Basic Principles
Table 5.1  Phases, tasks and issues in the family life-cycle
Phase Task Issues
Pairing/marriage Fusion Leaving family of origin (emotionally and physically);
readiness for intimacy (psychological and sexual);
agreeing roles, goals and values
complementarity/symmetry of marital relationship
Child-bearing Creation Sharing each other; role ambiguity—wife, woman or
mother?;
two's company, three's a crowd pairing off
School-age children Nurturing Providing security (emotional and
environmental); how to be a parent;
separation; involvement with community; mother with more
time again; differences between children
Family with adolescent Boundary-testing Control versus freedom; power struggle and rebellion;
children individuation; social and sexual exploration
Family as 'launching Leaving/letting go Changing roles of children still at home; the empty nest—
ground' loss or opportunity?; parents rediscover each other; latent
marital conflict
Middle years Reviewing/reappraising Mid-life crisis; fulfilment/disappointment; accepting
limitations; changing self-image; anticipating retirement;
death of parents
Old age Intimations of mortality Aging, illness and death; closing-in of boundaries; achieving
serenity; religion and philosophy; isolation/dependency;
bereavement

Stages stage then becomes an opportunity for health

™™ Newly married (couples without children)
™™ Birth of first child (eldest child from birth
– 30 months)
™™ With preschool children (eldest 2½–6
years.)
™™ With children in school (oldest 6–13 years.)
™™ With teenagers (eldest 13–20 years.)
™™ Launching years—Empty nest phase—
(children leaving home; adjusting to the
ending of parenting roles)
™™ Parents alone in middle years (from last
child leaving home till retirement of the
parents).
™™ Retirement and later years (from retirement
to the death of one or both parents).
For the family each new developmental
stage opens up fresh responsibilities, whereas
for the family doctor each new stage alerts to
what may be expected and an approximate
period for anticipating change. Each new
promotion and intervention.
While the newly married learn to establish
a mutually satisfying relationship and adjust to
each other and help one another meet social,
economic and sexual needs, the doctor can
integrate health practices and habits into the
lifestyle of the couple, which promote health
and prevent disease. For example: practicing
hygiene; participating in well-balanced
programs of rest, exercise, and a balanced
diet; advice on safe sex; knowledge concerning
contraception, pregnancy and marital roles
and adjustments. The family doctor has to
consciously work out health practices that are
most suitable to the couple’s lifestyle, which
will promote health as an invaluable asset at
the very beginning of the family life cycle.
With the birth of the first child, the couple’s
functions and responsibilities expand. The
work needs rescheduling and becomes more
stressful, financial strain increases and leisure

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 Chapter 5: The “Family” in Family Medicine 41
activities decrease. First time parents often
feel the lack of emotional support during
the first few months of parenthood. Here the
family physician can analyze the child-rearing
needs of the family, advice on the appropriate
use of resources for child care, including
breast feeding, scheduling immunizations,
monitoring growth and mile-stones, and
advice on childhood behavioral problems.
When the children grow up into teenagers—
each growing and developing at an individual
pace—great demands are placed on the
family, which must meet the critical needs
and interests of the children. Promoting
religious practices, education, sound health,
and disciplinary techniques are critical tasks
in socialization of children. At this stage, the
family physician can advice the teenagers
on developmental changes, intersibling
relationship, sexual health and hygiene. Health
problems in this age group include violent
deaths (homicide and suicide), accidents,
alcohol and drug abuse. The family physician
needs to analyze the conflicts, if any, between
parents and children, assess risks for engaging
in certain harmful behaviors, and emphasize
the benefits of practicing healthy behaviors.
When children grow to adulthood,
they begin to leave home. The last child
departing from home may create an “empty
nest syndrome”. The parents have to realign
their priorities, adjust to retirement and its
consequences, and cope up with the aging
process. The social circle decreases and
loneliness increases. Health tasks require
a new awareness because of susceptibility
or vulnerability to illness and diseases. At
this stage, the family physician can help
decrease risks by placing a high value on
physical activity, adequate nutritional
requirements, not smoking, adjusting home
environment to be safe and comfortable, and
also providing counseling and psychological
support to overcome loneliness and deal with
bereavement.
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The “structure” (i.e. family roles and
relationships) and “functions” (i.e. the process
of continuous change in the system) of
the family is a dynamic process, which
keeps altering with the passage of time. The
physician and the family together work to
accommodate and adapt additional tasks and
change their plans as necessary. Failure of the
family members to adapt to the changes can
be a source of ill health. The family physician’s
interventions are aimed at assisting the family
in carrying out functions it cannot perform
by itself. In health promotion and disease
prevention, the physician assists the family in
improving its capacity to understand stressful
events inherent to such situations and guide
the family to its best advantage.
Family Dynamics and Illness
Family dynamics may be broadly defined as
the relationship of an individual person in the
context of his/her family, the interpersonal
relationship within other family members, and
the relationship of the family to the community.
One of the defining characteristics of family
medicine has always been the special
relationship family physicians have with their
patients and that “the patient is viewed in the
context of the family and the family in the
context of the community.”
Families have a life of their own that is
distinct from, yet always connected to, the lives
of the individual family members.
An individual’s family relationship is an
important determinant of health and disease,
and family dynamics are connected vitally
to the basic issues of health promotion and
disease prevention in any family. The healthy
family “equilibrium” can get disturbed by
an illness, disability, and social deprivation,
and it is essential for the family physician to
recognize and manage any illness with a clear
understanding of the dynamics of the family
life to set right this “equilibrium.”
 42  Section 1: Basic Principles
The patient’s perception of his illness
may be different from the doctor’s because
of family’s preconceived ideas, faith, and
experiences. The family culture comprises
of habits, beliefs, and lifestyles, which may
aggravate or alleviate an illness of its members.
Therefore, the family physician must be able
to meet the healthcare needs of patients
from diverse culture and socioeconomic
backgrounds, and to understand illness in the
context of cultural beliefs and norms so as to
provide effective care.
In a broader context, the implication of
family dynamics extends beyond the family
per se. Family physician needs a community
orientation with its health beliefs in an illness,
the cultural morals that affect healthcare, and
the social, economical, and physical factors
that may be related directly or otherwise to
community morbidity and mortality.
The other important aspects of family
dynamics include:
™™ To recognize the impact of illness on
the family — The individual with an
illness creates physical, mental, and
financial strain within the family. The
imperative needs and caring of the sick
person with its subsequent responsibilities
and consequences in the other family
members can lead to conflicts, resentment,
anxiety, and depression. This especially
occurs when the illness is prolonged,
chronic and serious. The family with strong
personal bonds will accept such illness as a
challenge to adapt, to grow up, and to make
relationship stronger.
™™ To plan and execute allocation of scarce
health resources, including preventive
and curative measures, to the family’s best
advantage. The family physician has to
analyze the advantages and disadvantages
of both short and long term cost-effective
healthcare measures in the context of
family resources, desires, behavior, and
relationship patterns.
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™™ When working with families under
stress, e.g. due to a serious illness of
its member, it is best not to judge their
roles or relationship patterns. By offering
support and affirmation of their family
rules and roles, the family physician can
gain their confidence by offering choices
and alternatives, which are likely to affect
a positive change.
Certain diseases and disorders are well
known to be either initiated or exacerbated by
factors involved in the family dynamics. For
example, parental difficulties, such as marital
conflicts, are associated with bronchial asthma
in already susceptible individuals. Stressful
experience may result in the inception of
asthma, exacerbations, and inadequate
control. Stressful family events, such as marital
disharmony, divorce, death of a parent, or
a family member are frequently associated
with maladaptive behavior in children.
The incidence of migraine, irritable bowel
syndrome, anorexia/bulimia nervosa, etc. is
higher in stressful families.12,13
In certain situations a cooperative and
encouraging family dynamics is extremely
helpful in achieving positive results. For
example, a significant number of individuals
have quit smoking and other related
deleterious health habits only by the morale
booster support of their family members. A
holistic involvement of family members in
many diseases and disasters has proved to be
a critical factor in their final outcome.14,15
Thus, to understand the family dynamics,
the family physician needs to follow
“biopsychosocial model” of illness, considering
simultaneously physical, psychological, social,
and environmental factors in assessing health
and illness in their patients, rather than the
“biomedical model” (i.e. all illness has a single
underlying cause, disease is always the single
cause, and removal or attenuation of the disease
will result in a return to health) followed in
routine clinical practice.16 This is important in
 Chapter 5: The “Family” in Family Medicine 43
the early stages which unables to understand
the relationship between the life events and
the onset of the disease; and in the late stages it
helps to make effective plans for continuing care.
Risk Factor Estimates
Throughout the family’s life cycle, family
members are prone to develop age-specific
risk factors, which may ultimately lead to an
illness with its subsequent morbidity and
mortality. For example:
™™ In a child-bearing family, risk factors
such as lack of prenatal care, poor food
habits, smoking, alcohol, drug abuse,
low socioeconomic levels, etc. may lead
to premature labor, low birth weight
infants, birth defects, sudden infant death
syndrome, fetal alcohol syndrome, etc.
™™ In a family with adolescents, risk factors
such as conflicts between parents and
children, rigid family values, pressure to live
up to family expectations, school problems,
etc. are known to cause depression and
lead children to acts of deliberate self-
harm, including suicide.
™™ In a family with middle-aged adults, risk
factors such as hypertension, diabetes,
overweight, physical inactivity, stress, etc.
are well known to cause coronary artery
diseases and cerebrovascular accidents.
™™ In a family with elders, risk factors such
as retirement, reduced income, loss of
spouse, lack of exercise, failing vision,
hearing, sight, etc. are prone to cause
depression, mental confusion, and injuries
such as falls, acute illness, chronic diseases,
and even death without dignity.
Generally, the risks that are family related
can be inferred from:
™™ Biological factors—genetic inheritance,
congenital malformation, mental retardation,
™™ Lifestyle factors—dietary habits, physical
activities, smoking, alcohol, drug abuse,
sexual habits
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™™ Environmental factors—work pressure,
stress, pollution, travel
™™ Social and psychological factors—crowding,
isolation, fast-life
™™ Healthcare system—overuse, under use,
inappropriate use.
Family physicians need to be aware of such
risk factors prone to cause health problems
to which a family may be most vulnerable or
sensitive so that appropriate health promotion
and disease prevention strategies can be
instituted. Moreover, awareness of risk factors
may prompt families to make an extra effort to
reduce risks more directly under their control
and thus lessen overall risk of disease and injury.
Assessment of Family
Dynamics/Illness7
The family physician can adopt some of the
following methods to evaluate the family
dynamics:
™™ Self-report method—The physician asks
family members, individually, together
or both regarding problems. A more
refined or objective method of collecting
self-perceptions is to use standardized
inventories or questionnaires.
™™ Observation method—Carefully observing
family members interacting during
consultation.
™™ Impromptu method—An ‘impromptu’
home visit (with some pretext such as
an inquiry about relative’s health or lab
report) on the way home from office may
be very revealing. The ‘surprise’ element
may provide factual information in some
persistent and problematic cases.
™™ Family interview—Inviting the whole
family to a counseling session, if required.
Family in Crisis
Although, we all strive for perfection, there
is no perfect family. Each family has its
own strengths and weaknesses, assets and
 44  Section 1: Basic Principles
liabilities, challenges and problems. Each
family develops its own ways of coping with
these stresses, some of which work better than
others. But sometimes problems lead to crisis.
A family crisis may be defined as a problem
that cannot be solved or addressed with the
family’s normal or customary problem solving
skills. It is a state of affairs in which a decisive
change one-way or the other is impending. In
other words a crisis is a “turning point”, and an
“upset in a steady state”. When a situation, such
as a serious illness, produces a disturbance in
the steady state, i.e. “equilibrium”, the person
activates problem solving activities and coping
mechanisms to restore equilibrium. If the stress
is such that it pushes the person beyond the
ability to restore the equilibrium, crisis will result.
Some common examples of cr isis
situations in a family are: critical illness,
accidental events, natural disasters, criminal
acts, suicide, terminal illness, death, HIV
diagnosis, rape, sexual abuse, substance abuse,
unemployment, career changes, financial
problems, separation or divorce, and so on.
A stressful event need not necessarily
constitute a crisis; the individual’s or family’s
perception of and response to the event
determine if a crisis will occur. For example:
death of a loved one may be viewed as crisis, but
it may not constitute crisis for those individuals
or families who do not perceive the event as
such and who manage to resolve the event
by using their usual coping behaviors and
situational supports. Thus, the ability of families
to respond to a crisis depends on the resources
they have—both physical and emotional. Sound
decision-making, confidence, communication,
unity, supportive friends and relatives are some
of the crucial factors that are helpful in a crisis
management (Fig. 5.1).
Caplan’s Model of Crisis Intervention
Using Caplan’s model, there are three levels of
crisis intervention.17
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1. Primary Prevention: These are activities
designed to prevent a crisis from occurring.
2. Secondary Prevention: These are steps
taken in the immediate aftermath of the
crisis to minimize the effects.
3. Tertiary Prevention: This provides long-
term follow-up to those most affected.
Transition Stages During a Crisis
The following stages usually occur during any
severe crisis:
™™ Numbness/shock (Emotional inability to
accept the reality of death),
™™ Denial (This cannot be happening; refuse
to acknowledge the death of loved one
or other loss, and make every attempt to
continue on with daily routine as though
nothing has changed),
™™ Anger (The need to find someone to blame
for the loss occurs, e.g. blaming God,
doctors, destiny),
™™ Depression (Sadness, hopelessness, loss
of appetite, changes in sleeping patterns),
and
™™ Acceptance of reality (moving on with
normal life after the loss has occurred; the
reality of the loss comes into focus, the
grieving person accepts the loss and begin
rebuilding his life).
Risk Factors for Crisis
In addition to the factors which are features
of disturbed families discussed above,
identification of additional risk factors leading
to crisis situation are especially helpful for
anticipatory planning, including primary
prevention of crisis. These include:
™™ History of frequent crisis, ineffectively
resolved because of poor coping ability
™™ Low self-esteem
™™ History of mental disorder or emotional
instability
 Chapter 5: The “Family” in Family Medicine 45

Fig. 5.1  Paradigm of effect of balancing factors in stressful event. (Source: Aguilera DC: Crisis
Intervation: theory and methodology, edn 6, St Louis. 1990. Mosby.)
*Balancing factors

™™ Tendency toward impulsive “acting out”
behavior—doing without thinking
™™ History of numerous accidents
™™ Frequent encounters with law/judicial
agencies.
It is extremely important to recognize that
family crisis have an impact upon all family
members. In the long term, other family
members may be affected more than the
individual actually suffering. This may apply
particularly to children manifesting in them
as behavioral disturbances, poor scholastic
performance and other aberrative habits later
in their life.7
During crisis, the obvious priority for the
physician is the patient, but the less obvious
needs of the family should not be ignored.
Physician’s Role in Family Crisis7
An individual or family, in a state of crisis
needs immediate help to solve the crisis,
with the focus of what is happening here
and now.
Crisis intervention is a short-term mode of
therapy for assisting individuals and families
to cope with current crisis events. Although
cautious, short-term use of benzodiazepines
may be advocated in specific situations, the

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 46  Section 1: Basic Principles
family physician should aim at two areas of
crisis intervention; namely—to get actively
involved with the family to help restore
equilibrium, and to obtain help of the family’s
significant others to assist in solving the
immediate crisis. Following steps should be
actively considered:
™™ Assess the individual or family for possible
reasons leading to crisis before planning a
strategy for intervention.
™™ Once the initial assessment is completed,
provide help to the individual or the
family to supplement personal strengths
to avoid a crisis state and future health
consequences.
™™ Involve as many family members as
possible in the early stages of any critical
illness. Arrange family conference, if
necessary.
™™ Discuss and decide management issues
with family members. Always respect their
views and wishes.
™™ Include the family on a continuing
basis—especially if a long-term illness is
anticipated.
™™ Include the family in hospital discharge
and subsequent follow-up visits.
™™ If the family seems overwhelmed with
problems, or if there is a breakdown in
relationship within the family, it is probably
time to arrange for expert professional
help.
The ultimate goal of crisis intervention is
assisting individual/family to function at a
higher level than their present state.
Family-based Medical Counseling
—The “Bathe” Technique18,19
Numerous studies confirm that emotional
problems are prevalent in patients who
present to family physicians.17,20 Therefore,
they need an effective method of incorporating
psychotherapy into the patient’s visit.
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Among many psychotherapeutic counseling
models available to assist the family physician,
the BATHE model is highly useful.
The acronym BATHE refers to the
components of the interview. This interview
format allows the physician to assess the
Background situation, the patient’s Affect,
the problem that is most Troubling for the
patient and the manner in which the patient
is Handling the problem. It concludes with a
response that conveys Empathy.
Using the ‘BATHE’ Technique
The family physician can usually elicit the
background situation for the patient visits
with a simple statement such as “Tell me what
has been happening in your life; is there any
change since you last fell sick.” This conveys
the physician’s interest and invites the patient
to share any present concerns. The physician
then moves forward and clarifies the patients
affect, i.e. emotional state by asking, “How
do you feel about what is going on in your
life; how do you feel about your home/work/
spouse/children”. Similarly, the question “what
troubles or worries you most in your life/at
home” helps the patient to focus and provides
understanding and insight for both physician
and patient. Based on the response, the central
concern can often be identified.
The physician then asks how the patient is
handling the situation, e.g. “How do you feel
you are coping; do you get any support from
any one else.” Discussions on such questions
make the physician believe that the patient is
able to cope and the patient in turn appreciates
that his physician understands his method
of dealing with the problem. The patient
may even wish to work with his physician to
develop new coping strategies.
The technique concludes with an
empathetic response by the physician. A
response of this type conveys understanding
and support. Empathy is shown by authentic
 Chapter 5: The “Family” in Family Medicine 47

and sincere remarks, such as “That must have just a few of the characteristics of the humane
been very difficult; that sounds really tough on physician. Every physician will, at times, be
you.” Empathy is vital to establish and maintain challenged by patients who evoke strongly
a working relationship between patient and negative (and occasionally strongly positive)
physician. emotional responses. Physicians should be
While the BATHE technique may appear alert to their own reactions to such patients
elementary, it embodies many essential and situations and should consciously monitor
elements of successful psychotherapy. These and control their behavior so that the patient’s
elements include the establishment of a best interests remain the principal motivation
therapeutic alliance, empathy on the part of for their reactions all the time.22
physician, identification of the central conflict,
Physicians should create proactive patients by:
the development of insight and awareness,
™™ Giving them the essential facts and the
and the discouragement of dependency. In
treatment options and then be invited
particular, the BATHE technique discourages
to make their own choice. Although
dependency and encourages adaptation and
patients yield to the physician for their final
establishment of realistic coping strategies.
decision, they however want to learn how
and why he or she arrived at the decision.
Working with Families—Avoiding Most of the patients look for an element of
Pitfalls direction from their physicians.
Physicians are widely criticized for being too ™™ Asking for feedback and responding to it
paternalistic*—assuming the role of a ‘saviour’ (e.g. are you satisfied with the explanation;
or ‘rescuer’. This trait is found more commonly do you have any more questions).
in family physicians, who, because of their ™™ Emphasizing that all the family members
sustained patient-physician relationship over have to work together for maximum
the years with one or more families can easily benefits.
get trapped in the role of paternalistic “doctor ™™ Maintaining confidentiality of the
knows best” model in medicine. The best individuals within the family.
defense against this trap is for the physician to ™™ Avoiding taking sides and/or looking for
respect and restore the family’s autonomy**.21 scapegoats within the family.
Availability, the expression of sincere concern, ™™ Encouraging them to bring along a family
the willingness to take the time to explain all member to support them and to speak up
aspects of the illness, and an attitude of being if necessary.
non-judgmental with patients who have ™™ Involving another family colleague when
lifestyles, attitudes, and values different from important policy-decisions are involved.
those of the physician and which he or she To sum up, working with the families is an
may in some instances even find repugnant are important part of medical practice. Therefore,
*
Paternalism is the unjustifiable substitution of the judgment of the physician for the patient in deciding
what is best. It describes a “father knows best” set of attitudes and behaviors that would limit full disclosure
of medical information with patients and make decisions for patients without their input into the decision
making process.
**
Autonomy is the ability of an individual to determine his/her course of life. Practically speaking, autonomy
in medical practice means that individuals are free to choose and reject medical advice and that patients
are to be fully informed about their medical condition and, as much as is practical, take part in all decision
making that affects them.

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 48  Section 1: Basic Principles
it is the physicians’ duty to treat them, as they
would like to be treated themselves. Be honest
and respectful and make this contract with
them a pleasure.
References
1. http://www.searo.who.int/en/section13.htm
(Accessed on 03-10-2011)
2. Gardner J, et al. Is family therapy the most
effective treatment for anorexia nervosa?
Psychiatr Danub. 2011;23(Suppl)1:S175–7.
[PMID: 21894130: Abstract].
3. Campbell TL. The family’s impact on health:
a critical review and annotated bibliography.
Fam Syst Med, 1984;(2,3):135–328.
4. Campbell TL, et al. The effectiveness of family
interventions in the treatment of physical
illness. Journal of Marital and Family Therapy,
21, 545–83.
5. James Dennis, 1969. In: General practice, ed
John Murtage, The Family, 1996.p.9–10.
6. McDaniel SH, et al. Family-oriented primary
care: a manual for medical providers, 2nd edn.
New Yory:Springer-Veriag, 2003.
7. Benjamin Schlesinger. Strength in families:
Accentuating the positive; In: Contemporary
Family Trends series. Web site: file:///C:/
DOCUME~1/personal/LOCALS~1/Temp/
CFT_strengths_families_accentuating_
positive.pdf (accessed on 04-0402025).
8. John Murtage. General Practice: The Family,
1996:9–10.
9. Pratt L. Family structure and effective health
behavior: the energized family. Houghton
Mifflin, Boston, 1976.
10. Neighbour RH. The family life cycle R Soc Med.
1985;78 (Suppl 8):11–5. [PMID: 4009579; Free
full text]
11. Duvall EM, et al. Marriage and family develop­
ment. 6th ed. New York, 1985 [Harper and Row].
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12. Mangan JM, et al. The potential for reducing
asthma disparities through improved family
and social function and modified health
behaviors. Chest, 2007;132(5 Suppl):789S–
801S. Review [PMID: 17998343: Free article].
13. Vázquez Nava F, et al. [The asthmatic patient
and his/her family dynamics]. Rev Alerg Mex.
2003;50(6):214–9 [PMID:14968985:Abstract].
14. Shoham V, et al. A family consultation
intervent­ion for health-compromised smokers.
J Subst Abuse Treat, 2006;31(4):395–402. Epub
2006 Aug 14. [PMID: 17084793 :Free full text].
15. Wen X, et al Analysis on the influence factors
of parental participation in prevention and
control of smoking among secondary school
students. Wei Sheng Yan Jiu, 2007;36(3):323–6.
[PMID: 17712952: Abstract].
16. Wade DT, et al. Do biomedical models of illness
make for good healthcare systems? BMJ, 2004;
329(7479):1398–401. [PMID: 15591570: Free
full text].
17. Alan Rosen. Crisis management in the
community. Web site - http://www.mja.com.
au/public/mentalhealth/articles/rosen/rosen.
html. Accessed on 05-10-2011.
18. Stuart MR, Leiberman JA. The 15 minute
hour: Applied psychotherapy for primary care
physician, 2nd edn., Westport.Conn: Praeger,
1993:101–83.
19. Mcculloch J, et al. Psychotherapy for primary
physician: The BATHE technique: American
Acad of Fam Phy. American Family Physician,
1998.
20. Johnstone A, et al. Psychiatric screening in
Gen. Pract. - A controlled trial; Lancet, 1976;
1(7960):605–8.
21. Savage R.et al. Effect of GP’s consulting style on
patients’ satisfaction; A controlled study. BMJ,
1990;301:968–70.
22. The editors. The Practice of medicine. In:
Harrison’s Principles of Internal Medicine, ed.
Longo et al. 18th edn. Vol.1, p.6.
 2
Section

Health for All

™™ The Alma-Ata Declaration
™™ Primary Health Care Approach to Health for All

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mebooksfree.com
 6 The ALMA-ATA
declaration

“The Alma-Ata Declaration is the real revolution that enables us to restore genuine concepts in the
activities of our Organization. This Organization in the past had lost its way and steered away from the
main path of its work; it had sought to tackle individual diseases or develop health services in isolation
from one another. It had forgotten that health is a comprehensive movement or action, which starts and
ends with the individual. And without this concept I do not believe we can achieve a better world for the
individual.”
—Dr AL-AWADI (Kuwait), WHO Regional participant for Eastern
Mediterranean region; Round Table Debate, 10th Anniv.
Of Alma-Ata, 9th May 1988, Riga, USSR.

Background By the 1970s, the morbidity and mortality

The 1960s and 1970s many developing
countries in Asia, Africa, and Europe won
independence from former colonial powers.
This independence was accompanied by
an enthusiasm to provide high-standard
healthcare, education and other services for
the people. Governments moved to establish
teaching hospitals and medical and nursing
schools, often with the assistance of donor
nations. With rapid advances in medicine and
its technology, and subsequent specialization
by doctors in various medical sub-specialities,
it was realized that in both developed and
developing countries, health services favoured
only the privileged few. Although “health”
was the fundamental human right, there was
a denial of this right to millions of people
stricken with poverty and ill-health. Healthcare
services to the rural majority were supplied by
missionary hospitals and clinics, or by “touring
services” provided from urban hospitals.
There was a wide variety of services of varying
standard and quality in the rural areas. Most of
the population still visited traditional healers.1
for rural communities was not improving, and
in some places they deteriorated. In places
where people did have access to services,
cultural beliefs about illness meant those
services were not being accessed.
Further, developments such as oral
rehydration solutions, showed that early
and appropriate intervention by carers and
village volunteers could avoid referral and
admission to hospital, and, if combined with
an effectively organized vaccination program,
would address the major causes of death and
illness.2-4
During the 1970s, a synthesis of these
concepts was undertaken by the WHO
and UNICEF. It addressed the need for
a fundamental change in the delivery of
healthcare services in developing countries,
with an emphasis on equity and access at
affordable cost, and emphasizing prevention
while still providing appropriate curative
services. Thus, in order to render social justice
and equity to health care, the joint WHO-
UNICEF International Conference in 1978 at

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 52  Section 2: Health for All
Alma-Ata, (now called Almaty), USSR, called
for the revolutionary approach to global health
care.
The Genesis of Alma-Ata
The International conference on PHC, held
at Alma-Ata, USSR, in 1978, was convened
in response to an international sense of
despair over the widespread inequalities in
health and health care that afflicted all the
nations of the world, developed as well as
developing. Despite great efforts by countries
and WHO in the late 1960s and early 1970s to
improve and extend services, large number
of people, particularly in the rural areas of
developing countries, remained with no access
to basic healthcare and hygiene. This attracted
worldwide criticism as “social injustice.”5 The
global conscious was stirred leading to a new
awaking that the health gap between the rich
and the poor within countries and between
countries should be narrowed and ultimately
eliminated.
Primary Health Care Takes Center
Stage
Discussing these issues at the joint WHO-
UNICEF International Conference in 1978 at
Alma-Ata, USSR, participated by delegations
from 134 member states, and by representatives
of 67 Unite d Nations Organizations,
specialized agencies and non-governmental
organizations, called for a “revolutionary
approach” to health care. Declaring that,
“The existing gross inequalities in the health
status of people, particularly between the
developed and developing countries, as well
as within countries is politically, socially and
economically unacceptable”, the Alma-Ata
conference called for acceptance of WHO
goal of “Health For All (HFA) by 2000 AD” and
proclaimed as way of achieving HFA.6
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Declaration of Alma-Ata
The International Conference on Primary
Health Care (PHC), meeting in Alma-Ata this
12th day of September in the year Nineteen
hundred and seventy-eight, expressing the
need for urgent action by all governments,
all health and development workers, and the
world community to protect and promote the
health of all the people of the world, hereby
makes the following declaration:
™™ The conference strongly reaffirms that
health, which is a state of complete
physical, mental and social well-being,
and not merely the absence of disease or
infirmity, is a fundamental human right
and that the attainment of the highest
possible level of health is a most important
world-wide social goal whose realization
requires the action of many other social
and economic sectors in addition to the
health sector.
™™ The existing gross inequality in the health
status of the people particularly between
developed and developing countries as
well as within countries is politically,
socially and economically unacceptable
and is, therefore, of common concern to
all countries.
™™ Economic and social development, based
on a New International Economic Order, is
of basic importance to the fullest attainment
of health for all and to the reduction of
the gap between the health status of the
developing and developed countries. The
promotion and protection of the health
of the people is essential to sustained
economic and social development and
contributes to a better quality of life and
to world peace.
™™ The people have the right and duty to
participate individually and collectively in
the planning and implementation of their
health care.
 Chapter 6: The Alma-Ata Declaration 53
™™ Governments have a responsibility for the
health of their people, which can be fulfilled
only by the provision of adequate health
and social measures. A main social target of
governments, international organizations
and the whole world community in the
coming decades should be the attainment
by all peoples of the world by the year
2000 of a level of health that will permit
them to lead a socially and economically
productive life. PHC is the key to attaining
this target as part of development in the
spirit of social justice.
™™ Primary health care is essential health care
based on practical, scientifically sound
and socially acceptable methods and
technology made universally accessible to
individuals and families in the community
through their full participation and at
a cost that the community and country
can afford to maintain at every stage of
their development in the spirit of self-
reliance and self-determination. It forms
an integral part both of the country’s
health system, of which it is the central
function and main focus, and of the overall
social and economic development of the
community. It is the first level of contact
of individuals, the family and community
with the national health system bringing
health care as close as possible to where
people live and work, and constitutes the
first element of a continuing health care
process.
™™ Primary health care*
ƒƒ Reflects and evolves from the economic
conditions and sociocultural and
political characteristics of the country
and its communities and is based on
the application of the relevant results of
social, biomedical and health services
research and public health experience.
*Ref. Appendix 4
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ƒƒ Addresses the main health problems in
the community, providing promotive,
preventive, curative and rehabilitative
services accordingly.
ƒƒ Includes at least education concerning
prevailing health problems and
the methods of preventing and
controlling them; promotion of food
supply and proper nutrition; an
adequate supply of safe water and
basic sanitation; maternal and child
health care, including family planning;
immunization against the major
infectious diseases; prevention and
control of locally endemic diseases;
appropriate treatment of common
diseases and injuries; and provision of
essential drugs.
ƒƒ Involves, in addition to the health
s e c t o r, a l l re l at e d s e c t o r s a n d
aspects of national and community
development, in particular agriculture,
animal husbandry, food, industry,
education, housing, public works,
communications and other sectors;
and demands the coordinated efforts
of all those sectors.
ƒƒ Requires and promotes maximum
community and individual self-reliance
and participation in the planning,
organization, operation and control
of PHC, making fullest use of local,
national and other available resources;
and to this end develops through
appropriate education the ability of
communities to participate.
ƒƒ Should be sustained by integrated,
functional and mutually supportive
referral systems, leading to the
progressive improvement of compre­
hensive health care for all, and giving
priority to those most in need.
 54  Section 2: Health for All
ƒƒ Relies, at local and referral levels, on
health workers, including physicians,
nurses, midwives, auxiliaries and
community workers as applicable,
as well as traditional practitioners as
needed, suitably trained socially and
technically to work as a health team
and to respond to the expressed health
needs of the community.
™™ All governments should formulate national
policies, strategies and plans of action
to launch and sustain PHC as part of a
comprehensive national health system and
in coordination with other sectors. To this
end, it will be necessary to exercise political
will, to mobilize the country’s resources
and to use available external resources
rationally.
™™ All countries should cooperate in a spirit of
partnership and service to ensure PHC for
all people since the attainment of health
by people in any one country directly
concerns and benefits every other country.
In this context, the joint WHO/UNICEF
report on PHC constitutes a solid basis for
the further development and operation of
PHC throughout the world.
™™ An acceptable level of health for all the
people of the world by the year 2000 can
be attained through a fuller and better use
of the world’s resources, a considerable
part of which is now spent on armaments
and military conflicts. A genuine policy
of independence, peace, détente and
disarmament could and should release
additional resources that could well be
devoted to peaceful aims and in particular
to the acceleration of social and economic
development of which primary health care,
as an essential part, should be allotted its
proper share.
The International Conference on PHC
calls for urgent and effective national
and international action to develop and
implement PHC throughout the world and
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particularly in developing countries in a
spirit of technical cooperation and in keeping
with a New International Economic Order.
It urges governments, WHO and UNICEF,
and other international organizations, as
well as multilateral and bilateral agencies,
non-governmental organizations, funding
agencies, all health workers and the whole
world community to support national
and international commitment to prima
PHC and to channel increased technical
and financial support to it, particularly in
developing countries. The Conference calls
on all the aforementioned to collaborate in
introducing, developing and maintaining PHC
in accordance with the spirit and content of
this declaration.
In summary, PHC is a strategy now
internationally accepted as the most important
means of meeting the health needs of people in
communities around the world. To implement
this strategy and improve the general level of
health amongst populations and in individuals,
cooperation and efforts must come from all
quarters of the organized health care field, the
public and social services, and from people
themselves in their communities.
References
1. Chan M. Director-General of the WHO;
Address at the WHO Congress on Traditional
Medicine. Web site - http://www.who.int/
dg/speeches/2008/20081107/en/index.html.
Accessed on 06-10-2011.
2. Editorial: Oral glucose/electrolyte therapy for
acute diarrhoea. Lancet, 1975;1(7898):79–80.
[PMID: 46028: Abstract].
3. Smith LG. Teaching treatment of mild, acute
diarrhea and secondary dehydration to
homeless parents. Public Health Rep, 1987;
102(5):539–42. [PMID: 3116585: Free full text].
4. The Mahler revolution [editorial]. BMJ, 1977;
1:1117– 8[PMID: 861491: Free full text].
5. Park K. Park’s Text Book of P&SM, 16th edn.: 1.
6. World Health Assembly Resolution–32.30, 34.60,
and 41.34: Strengthening primary health care.
 PRIMARY HEALTH

7 CARE APPROACH
TO HEALTH FOR ALL

““When I took office at the start of last year, I called for a revitalization of primary health care as an
approach to strengthening health systems. During the course of last year, I took that commitment a step
further. I became convinced that we will not be able to reach the health-related Millennium Development
Goals* unless we return to the values, principles, and approaches of primary health care.”
—Dr Margaret Chan

What is “Health for All”?
“Health For All (HFA)” is a rallying call to
the international community to enable “the
attainment by all citizens of the world by the
year 2000 of a level of health that will permit
them to lead a socially and economically
productive life.” The HFA is a battle cry to give
renewed impetus to the whole process of social
and economical development of which health
is a vital component.
Dr Somsak Chunharas, Chairman of World
Health Organization (WHO) Expert Group on
Revitalizing Primary Health Care has proposed a
new definition of “Health For All” without a time
definition for the process of revitalizing PHC,
which states, “A stage of health development
whereby everyone has access to quality health
care or practice self-care protected by financial
security so that no individual or family is
experiencing catastrophic expenditure that may
bring about impoverishment.”1
The HFA is actually a vision of health
development. For this reason, HFA does not
need a concrete timeline, although the target
set by the Alma-Ata Declaration was the year
2000. It is not a single, finite target. Rather, it is a
developmental process leading to progressive
improvement in the health of our people.
HFA Does Not Mean that
™™ The best health care will be made available
for all people to take care of all diseases.
™™ Nobody will be sick or disabled by the year
2000.
HFA Does Mean that
™™ Essential health care will be made available
to all individuals and families in an
acceptable and affordable way.
™™ There will be more equitable and need
based allocation of finite health resources.
HFA—The Fundamental Principle
The fundamental principle governing HFA
movement includes the following:
™™ Health is a basic human right.

*The eight MDG are: 1. Eradicate extreme poverty and hunger, 2. Achieve universal primary education,
3. Promote gender equality and empower women, 4. Reduce child mortality, 5. Improve maternal health,
6. Combat HIV/AIDS, malaria and other diseases, 7. Ensure environmental sustainability, and 8. Develop
a global partnership for development .

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 56  Section 2: Health for All
™™ Health resources should be more equitably
distributed between and within countries.
™™ People must be involved in the planning
and implementation of their health care
system.
™™ There must be political commitment on the
part of the government to the movement.
™™ Countries must take the initiative to solve
their problems, although they may need
international assistance.
™™ Health development is an inter-sectorial
activity that requires the co-operation of
many disciplines and experts.
The Genesis of Primary Health
Care2
The PHC movement*, as exemplified by the
Alma-Ata Declaration, came about because in
many developing countries people in rural and
poor areas were deprived of essential health
care. In such situations, there was an urgent
need to re-orient political and administrative
thinking, so as to achieve a more equitable
distribution of health resources. Alternative
ideas and methods to provide health care were
considered and tried. Several programmes
against some of the major scourges such
as malaria, TB, leprosy, filaria, etc. were
launched. It took some time for the WHO to
realize that these were not only expensive
but also required lengthy duration to provide
expected results. Discussing these issues at the
joint WHO-UNICEF international conference
in 1976 at Alma-Ata (now called Almaty),
the governments of 134 countries and many
voluntary agencies called for the “revolutionary
approach” to health care and proclaimed PHC
as a way to achieving HFA.
The Declaration of Alma-Ata, in its seventh
clause, states that PHC consist of at least eight
*In India, the concept of PHC was conceptualized in 1946, three decades before the Alma-Ata Declaration,
when Sir Joseph Bhore made recommendation that formed the basis for organization of basic health
services in India.
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elements described as “essential health care.”
They are:
™™ Education concerning prevailing health
problems and the methods of preventing
and controlling them,
™™ Promotion of food supply and proper
nutrition,
™™ An adequate supply of safe water and basic
sanitation,
™™ Maternal and child health care, including
family planning,
™™ Immunization against the major infectious
diseases,
™™ Prevention and control of locally endemic
diseases,
™™ Appropriate treatment of common diseases
and injuries, and
™™ Provision of essential drugs.
The Concept of PHC
PHC is the corner stone of HFA. It was and still is
the only rational, cost-effective strategy to achieve
basic health for the majority of the people.
The PHC concept incorporates certain
fundamental values common to the overall
process of development but with emphasis on
their application in the field of health as follows:
™™ Health is fundamentally related to the
availability and distribution of resources,
not just health resources such as doctors,
nurses, clinics, medicines, but also
other socioeconomic resources such as
education, water and food supply.
™™ PHC is thus concerned with ensuring that
the available health and social resources are
distributed equitably with due consideration
for those whose needs are greatest.
™™ Health is an integral part of overall develop­
ment. The factors influencing health are
these social, cultural and economic as well
as biological and environmental.
 Chapter 7: Primary Health Care Approach to Health for All 57

™™ The achievement of better health requires
much more involvement by people as
individuals, families and communities,
in taking action on their own behalf by
adopting healthy behavior and ensuring
healthy environment.
or city, a majority of the middle—and upper-
income group visit a private practitioner that
may be a general practitioner or a specialist,
or directly go to a hospital. In many developed
countries the family doctor serves as the first
point of contact.

Phc Definition1 The PHC Approach

It is a broad and comprehensive concept that
places national health development into the
overall social and economic development as
embraced in its definition: PHC is “essential
health care based on practical, scientifically
sound and socially acceptable methods and
technology made universally accessible to
individuals and families in the community
through their full participation and at a cost
that the community and country can afford to
maintain at every stage of their development in
the spirit of self-reliance and self-determination.
It forms an integral part of both the country’s
health system*, of which it is the central function
and main focus, and of the overall social and
economic development of the community. It is
the first level of contact of individuals, the family
and community with the national health system
bringing health care as close as possible to where
people live and work and constitutes the first
element of a continuing health care** process.”
Primary health care refers only to the first
level of contact or close-to-client health care.
This first level of contact varies from country to
country as well as by geographical area. In the
A well-organized health care system would
invariably encompass the following:
™™ Coverage of the population,
™™ Provision of comprehensive, essential care,
™™ Integration of preventive and curative
services,
™™ Co-ordination of primary, secondary and
tertiary health care services,***
™™ Mechanisms of quality control services,
and
™™ Adequate funding and equitable distribution
of resources for all relevant services.
Ingredients of PHC (Table 7.1)
High technology hospital-based health care is
vital to handle the complex disease spectrum.
But these expansive facilities should not be
used to tackle common health problems,
which can be more effectively managed by
PHC centers—public or private. How then
should we go about organizing an effective
PHC system? Four vital ingredients are
essential.
™™ A clinically competent profession,

rural area usually it is the health center, health ™™ A caring profession,

sub-center, health post or private practitioner ™™ A cost conscious profession, and
(doctor, nurse and midwife). In the urban area ™™ A more organized profession.

*A health system consists of all organizations, people and actions whose primary intent is to promote,
restore or maintain health.
**Continuing health care process denotes that health care does not stop at the primary level of care or
the first point of contact. If there is need for more comprehensive or sophisticated care the patient will be
referred to a higher level of care—secondary or tertiary level of care.
***Health care service refers to medical and public health services provided by both government (the health
sector) and the private sector. It covers modern and traditional medicine as well as services provided by
the community.

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 58  Section 2: Health for All
Table 7.1  How Phc works3
In developing countries
Community education programmes
Added training to traditional midwives
Encouraging and training community health workers  Life-style modification
Teaching nutrition
Maternal and child welfare
Clean water and provision of sanitation
Immunization programmes
A Clinically Competent Profession
The objective of the medical school must
be to train primary care doctors who can
undergo further training in specialization.
Clinical training, if it has to be more relevant
to the objectives, will have to include more
exposure to primary care settings. The range
of medical topics taught and the strategies
for management should also reflect the
epidemiology of community-based practice.
A Caring Profession
In PHC, the human element is crucial. Patients
and families must feel comfortable in relating
to their primary care doctor. They must have
the confidence that he will provide good sound
advice.
A Cost-conscious Profession
The health care can be made more cost
conscious and cost effective by proper planning
co-ordination and control of expenditure.
An Organized Profession
To avoid undue wastage and duplication, there
must be greater co-operation among health
care providers. The primary care physicians
and specialists play a complementary role
*Primary Health Care can be a misnomer as it is sometimes regarded as a “primitive” form of health care.
Perhaps it is time to re-label it as “Essential Health Care”.
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In developed countries
Stress control and crisis management
Weight control and dietary improvement
Special access programmes for disadvantaged groups
Family-oriented ambulatory care, in hand with
emergency care
Health screening
Care of adolescents and elderly
Table 7.2  Misperceptions of PHC
•  Only for the poor
•  Cheap and low-quality of care
•  Aimed at developing countries only
•  Only for rural areas, and deals with primary care
only
and their relationship should be one of mutual
respect and support.
State and government policies should be
modified so that every individual and family
has a primary care physician who guides the
whole health care system. The patient as a
consumer does not have adequate knowledge
to exercise his or her decision in matters
of health and may have misperceptions*
(Table 7.2). This is especially so when
symptoms are vague or where patients have
multiple pathologies requiring the attention
of different specialists.
This process of PHC service is not an attempt
to deny free access to health care. Instead, it is a
rational approach to ensure that relevant care
is given to patients according to the type and
level of need. In this way, patients, physician,
and specialist are assured of optimum care as
and when the situation demands.
The PHC requires the use of new
management skills in planning, organizing,
leading and controlling the results of
 Chapter 7: Primary Health Care Approach to Health for All 59
PHC programmes. Practical management
principles and techniques can be learned in
short workshops and can be supplemented
by reading and continuing education
programmes, seminars or workshops. It
means involving the people themselves in their
own health care through better diet, proper
exercise, simple remedies for common minor
ailments, and general improvement in lifestyle.
It also means that mass communication and
marketing skills must be used the maximum,
so that other disciplines outside the organized
health care field can contribute to the total care
effort. It means involving agriculturists, public
workers, business establishments, legislators,
and other leaders at all levels.
Phc Revival—Beyound Declaration
At the WHO’s South-East Asia Regional
Conference on Revitalizing Primary Health
Care (PHC),1 organized on 6–8 August 2008
in Jakarta, Indonesia, it was acknowledged
that the target of Health for All movement
which was part of the Alma-Ata Declaration
on primary health care in 1978 that was to be
achieved by the year 2000 has not yet been
accomplished. Dr Margaret Chan, Director-
General of the World Health Organization,
in her address “Return to Alma-Ata”, on
18 September 2008 states, “Nor could the
visionary thinkers in 1978 have foreseen
world events: an oil crisis, a global recession,
and the introduction, by development banks,
of structural adjustment programmes that
shifted national budgets away from the social
services, including health. As resources for
health diminished, selective approaches using
packages of interventions gained favor over
the intended aim of fundamentally reshaping
health care. The emergence of HIV/AIDS, the
associated resurgence of tuberculosis, and an
increase in malaria cases moved the focus of
international public health away from broad-
based programmes and toward the urgent
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management of high-mortality emergencies.
The rise of chronic diseases has uncovered
further problems—most risk factors lie outside
the direct control of the health sector.”4
Thus, the overall factors which limited
the progress of HFA by 2000 AD could be
summarized as follows:
™™ Insufficient political commitment to HFA,
™™ Slow socio-economic development,
™™ Unbalanced distribution of and weak
support for human resources,
™™ Weak health information system and
absence of baseline data,
™™ Rapid demographic and epidemiological
changes,
™™ Inappropriate use of, and allocation of
resources for high cost technology,
™™ Difficulty in inter-sectoral action for health,
™™ Pollution, poor food safety and lack of safe
water supply and sanitation,
™™ Natural and man-made disasters, and
™™ The continuous low status of women.
But despite an abject failure to reach the
target, the basic pillars of the PHC approach,
i.e. universal coverage, equity in health,
inter sectoral collaboration and community
participation, and use of appropriate technology
remain valid even today.
Health For All is holistic concept calling
for efforts in agriculture, education, housing,
communications and industry as well as in
health. Implicit in the strategy of HFA is the
realization that health is only a part of socio-
economic well being. Hence a broad based
movement of radical redistribution of economic
and political power and deep transformation
of ideas, attitudes and values are called for
to achieve HFA. The measures for poverty
alleviation and social justice hold the key to HFA
in all developing countries including India.
Conclusion
PHC is attracting renewed concern with
its basics as proclaimed in the Millennium
 60  Section 2: Health for All
Development Goals. Such a movement is of
vital importance as new threats to health are
continually emerging.
If health care is to be properly developed
and equitably distributed, there must
be reasonable and effective control and
coordination to the overall situation in a
given country. The health services have to be
reoriented and restructured towards this goal
of HFA.
To achieve this vision, the PHC approach
is valid for all countries today, and even of
tomorrow, until a better way is discovered.
Montegut AJ in his article titled, “To
achieve “Health For All” we must shift the
world’s paradigm to “primary care access for
all”5 reinforce and to this core philosophy by
stating, “Since the early 1950s, the WHO has
proposed programs to promote primary health
care around the world. From the 1978 Alma-Ata
Declaration to the current promulgation of the
Millennium Development Goals, the WHO has
tried to improve health in developing countries
through a focus on disease-oriented (vertical)
programs. The WHO and other organizations
have not focused on the horizontal role of
primary care. The expectations created by
these programs have not been met. Evidence
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demonstrates that the advent of health care
through a base of primary care improves
health better than through the traditional
vertical disease—oriented health programs
used around the globe. The global “family” of
family medicine must advocate for a shift from
the current solutions to one in which the family
doctor is part of a well-trained healthcare team
that can function in networks that incorporate
the vertical programs into a broad horizontal
approach for better access to primary care.
Perhaps in this way “Health For All” can be
achieved.”
References
1. Regional Conference on “Revitalizing Primary
Health Care” Jakarta, Indonesia, 2008. Web site
-http://www.searo.who.int/en/Section1243/
Section2538.htm. (Accessed on 07-10-2011).
2. Education and Health. A manual on health
education in PHC. WHO. Geneva. 1988.
3. World Health Forum, The world’s main health
problems. 1981;2(2):264–80.
4. Web site - http://www.who.int/dg/20080915/
en/index.html. (Accessed on 07-10-2011).
5. Montegut AJ. To achieve “Health For All” we
must shift the world’s paradigm to “primary
care access for all”. J Am Board Fam Med. 2007;
20(6):514–7 [PMID: 17954857: Free Article].
 3
Section

Clinical Approach
™™ The Spectrum of Clinical Diagnosis
™™ Investigations: General Principles

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 8 The spectrum of
clinical diagnosis

“The family physician must often diagnose what things are not, rather than what they are; must
sometimes make management decisions before, or instead of, disease decisions; and must frequently
ignore the temptation to be thorough”.
—Anthony Dixon. ‘There’s a lot of it about’: clinical strategies in family practice.
Journal of the Royal College of General Practitioners, 1986. pp.468–71.

Introduction Table 8.1 Common undifferentiated symptoms in

primary care
The discipline of family medicine is probably
•  Abdominal pain
the most difficult, complex, and challenging •  Anxiety
of the healing arts. Among the multitude of •  Back pain
characteristics of the discipline of general •  Change in weight
•  Chest pain
practice/family medicine as pronounced •  Cough
by WONCA, 1 one of the attributes family •  Depression
physicians shoulder is the responsibility for the •  Dizziness
•  Fatigue
“comprehensive care of unselected patients with
•  Headache
undifferentiated* problems”—the so-called •  Insomnia
undifferentiated illness syndrome— regardless •  Nervousness
of age, gender, illness, organ system affected, •  Sexual dysfunction
•  Shortness of breath
or methods used.2 •  Vaginal discharge
Since family physicians are at the very
front line of healthcare delivery system, and
also, as primary physicians shoulder the “diagnosis”** to facilitate early recognition of
responsibility of the early diagnosis in the the disease, which allows starting treatment in
maze of “undifferentiated” symptoms (Tables the early phases of development with the aim
8.1 and 8.2), it is important that physicians of modifying the natural course of the disease
develop a well-founded methodology for and also reduce the margin of error.

*Undifferentiated, meaning they are non-specific and very general in nature, and can be associated with
a number of causes.
**Prof. IR McWhinney, in his “Albert Wander Lecture” says,” I have avoided using the term diagnosis…
medicine has yet to evolve a universal acceptable definition of diagnosis. It is well-known, also, that general
practitioners solve many “problems” without making a diagnosis in the sense of making a statement about
etiology, or of assigning the patient’s illness to a place in the taxonomy of disease.” (Ref. - Proc. Roy. Soc.
Med., Vol.65, Nov. 1972; Albert wander Lecture, Meeting, June 21, 1972; and Chapter 21: Medical records).

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 64  Section 3: Clinical Approach
Table 8.2  Characteristics of symptoms seen in family
practice
•  Many suggest undifferentiated problems
•  Many symptoms are characteristic of early disease
•  Many symptoms suggest problems that are self-
limited
•  Many symptoms are a complex mixture of social,
emotional, and physical factors
•  M any symptoms are related to behavioural
problems
•  People present more than one symptom at each
encounter
Clinical Process—History and
symptomatology
However, a particular problem for physicians
in primary care is that the vast majority
of symptoms encountered is a complex
mixture of physical, social, and psychologic
components, and seem to defy a clearcut
organic explanation.3, 4 Often the patient masks
such symptoms with a somatic component.
In one study, no physical disorder could be
established in 30 to 75% of cases, even after
careful investigations.5 Compared to secondary
care, organic diseases (e.g. malignancy, CCF)
have low prevalence in primary care, hence
the link between symptoms and disease is less
robust. Further, in order to exclude organic
disease in primary care, a physician may
fall into a trap of undertaking investigations
beyond that are absolutely necessary. Since in
primary care or family practice, “diagnosis” is a
far more knotty issue, and over-investigation is
a constant temptation, the concept of “clinical
diagnosis”, i.e. a working hypothesis based on
collected symptom data, both subjective and
objective, which are used to consider potential
cause-and-effect relationships, without benefit
of laboratory tests or imaging modalities has
been stressed.6 Prof. BM Hegde, former Vice
*McWhinney further classifies cues into two major categories: 1- Certain cues, which are diagnostic and
allow the physician to immediately place the illness into a definite category; e.g. an urticaria following drug
administration; or cough in a patient with past history of pulmonary TB. 2- Probabilistic cue enables the
physician to form a hypothesis, but additional inquiry or testing is necessary to validate the hypothesis.
These probabilistic cues form the basis for hypothesis generation.
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Chancellor, Manipal Academy of Higher
Education, Manipal, affirms, “In this modern
era of hi-tech science, clinical medicine may
seem primitive to younger generation of
clinicians. But in reality, it provides an accurate
diagnosis in over 80% of the cases, where as
all the sophisticated investigations combined
together yield only about 10% more…clinical
medicine is not just marginally superior to
hi-tech medicine but is the only hope. If we
have to keep up the nobility of our profession—
to do most good to most people most of the
time—we have to relay on time honored and
time tested medicine. A small percentage
of patients will definitely need hi-powered
hi-tech medicine, but the large majority of
patients would do well with good bedside
clinical medicine.”
History
A well-taken history (i.e. patient’s views of
illness) is a record of patient’s experiences,
not only of the current illness for which
help is being sought, but also those related
to life, work, family situation and previous
health. In additions to these facts, the patient
continually offers valuable “clues”*, i.e.
discrete information which indicates the
nature of something perceived by the patient;
clues—whether verbal or non-verbal—are
always an indirect signal that patients use to try
to alert the doctor to a question or concern to
their attitude, knowledge and belief about their
health, which are valuable in total patient care
management. Further, certain clues should
alert the physician to avoid thinking solely in
clinico-pathological basis (Table 8.3).
In The Horse and Buggy Doctor, Hertzler7
wrote, “Having acquired a patient, the first
 Chapter 8: The Spectrum of Clinical Diagnosis 65
Table 8.3 Historical clues suggesting non clinico-
pathological illness
•  F requent attendance with the same somatic
symptoms.
•  Large or endless number of somatic symptoms.
•  Attendance with symptoms that has been present
for a long-time.
•  Inability to make sense, or being vague of the
presenting problem.
•  Conversation that is out of context.
•  Incompatibility between the patient’s distress and
the comparatively minor nature of the problem.
•  Body language — nervousness, tics, rigid posture.
thing to do is obtain a history of his aliment.
The securing of an adequate one is a work of
art. It requires knowledge of disease and of
human nature. It is hard work and it is time
consuming but it is necessary, because to
many cases it is the most important factor
in the whole procedure. A good history may
even anticipate what the microscopic slide will
show.” The symptom—the problem that brings
the patient to the physician—is the starting
point in the medical inquiry, and begins the
process of problem solving.
A complete medical history should contain
reasons for the patient’s concern (Table 8.4).
The elements of the history which are most
important in clinical diagnosis are those which
provide positive and negative defining features
of the “working hypothesis” (see below) being
tested. For example, in an adult, if the working
hypothesis is angina pectoris, the physician
will inquire about positive features such as
precordial pain of short duration, aggravated
on physical exertion, relived by rest, and its
radiation to arms, and tobacco abuse. Negative
features that exclude angina pectoris that must
also be inquired include: localized chest pain,
not related to exertion, lasting for long duration,
and history of musculoskeletal aliments.
Skills in History Taking
Taking the history is not simply a “question and
answer” session. It is a “dialogue” in which the
physician:
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Table 8.4  Patients’ reasons for seeing doctor
•  A new illness
•  An acute episode in a chronic problem
•  For repeat medications
•  Request for home visit
•  Request for referral or visit to another doctor
•  To discuss results of lab investigations
•  To follow-up previous consultation
•  To obtain certificates, signing bills, recommendation
letters
™™ “Listens with care”—to what the patient is
saying (see below),
™™ “Interprets”—what the patient is trying to
convey,
™™ “Elicits”—important/relevant information
not volunteered by the patient, and
™™ “Ascertains”—that the complaints which
the patient has not mentioned are indeed
absent.
Listen to Your Patients…and They will
Tell you the Diagnosis..!
Listening to the patient seems so obvious, and
yet so often neglected. Sometimes it is because
the doctor has memorized entire “textbook
of medicine” and assumes, arrogantly, that
he/she knows patient’s diagnosis better than
the patient does. At other times, it is because
the doctor is too distracted or lacks the time
to really listen and jumps to conclusions.
The patient knows his/her own body and
symptoms far better than a doctor or any
medical textbook. Therefore, a kind and
attentive doctor, who is willing to spare time to
listen to the patient—the feeling of not having
to hurry during the consultation—is more
important than the actual number of minutes,
and it is the most satisfactory therapy in the
majority of patients in family practice.8 As the
great clinician Lord Platt in the year 1949 wrote
– “if you listen to your patient long enough, he/
she will tell you what is wrong with him/her”.
This is as true today as it was centuries ago!
 66  Section 3: Clinical Approach
History taking, in which both the physician
and the patient participate in the “dialogue”,
therefore, it is not an isolated one-time
procedure. It is a dynamic process, which
should be refined during physical examination,
while reviewing investigations, and later
during the course of the illness.
Analysis of Symptoms9,10
Since ancient times*, patients have been
presenting to the physician with symptoms
and signs as expressions of their illness. These
presentations, i.e. symptoms and signs, have
not changed much over the centuries. But our
insights into what these represent have changed
greatly. For example, bacterial infections was the
most common cause of pyrexia a few decades
ago, but now, with the advent of new diagnostic
inventions, such as molecular biology, we now
have multi-drug resistant viruses, bacteria, and
immunodeficiency disorders as the common
causes in the etiopathogenesis of pyrexia. The
physician with the greatest insight into the
etiopathogenesis of illness is best equipped to
deal with the patient’s illness. The knowledge
into the insight of rare disorders further helps in
the treatment of the illness.
Often a symptom that has not concerned
the patient has little clinical significance; but
in certain situations a seemingly insignificant
complaint may have considerable importance.
For example, a smoker may ignore his cough
as a common smoker’s cough, but when
it is persistent, and associated with other
systemic manifestations, such as weight loss,
it is mandatory to rule out or confirm lung
malignancy. Therefore, the physician should
be constantly alert to the possibility that
any event related to the patient and family
members, however trivial or insignificant, may
be the clue to the solution of their illness.
*In the ancient world, medicine was closely allied with religion; problem solving was often attempted
through prayer, meditation, and revelation.
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Limitations of Symptoms
Although, it is common for disease process
to manifest themselves through symptoms,
physicians should be aware of their limitations
in certain conditions, for example:
™™ Absence of symptoms—e.g. absence
of chest pain in myocardial infarction,
especially in diabetic patients; viral
hepatitis without icterus, as in chronic
hepatitis B, or post-transfusion hepatitis;
™™ Atypical symptoms—e.g. patient with IHD
may c/o “indigestion/gas,” instead of chest
pain;
™™ Non-specific symptoms—e.g. patient
c/o fatigue may be a manifestation of
several organic disease, such as iron
deficiency anemia, or HIV infection, or
bowel cancer; or psychological illness,
such as depression, or substance abuse;
both simple and benign, or serious and
life-threatening;
™™ Identical symptoms—e.g. fever with chills
may be due to malaria, cystitis, abscess, or
pneumonia;
™™ Medically unexplained symptoms (MUS)—
Terms such as somatization, or functional
symptoms have been used to categorise
symptoms without an organic cause. It is
important to appreciate that MUS are not
synonymous with unimportant symptoms.
Further, even symptoms that have an
overt organic cause are interpreted and
described differently by patients according
to their personality, health beliefs, physical,
and psychological state. 11,12 Picking
up clues to identify problems that are
functional rather than organic is a key skill
for a successful family physician. A policy
of observation over a period of time may
further resolve the issue.
 Chapter 8: The Spectrum of Clinical Diagnosis 67
Patient—Symptoms Variables13,14
World Health Organization analysis shows
that in family practice over 70% of problems
which cause sickness are behavioural related.
Many patients seek medical care because
they want to tell to someone who will hear
and sympathize with their problems. They
believe that the only “ticket of admission” (see
below) to a physician’s consultation chamber
is by presenting a physical problem—so
they find one! A 30-year-old man complains
of dyspepsia, and asks the physician, “is
it stomach ulcer?” On physician’s careful
inquiry, it seems to be related to difficulties
he is having at home and work, which was
this patient’s prime concern, but was afraid to
discuss. Subsequently, physician’s counselling
relieved his dyspeptic symptoms to a great
extent.
Why do patients need “ticket if admission”?
Many patients would like to talk to a sympathetic
doctor about personal problems not parochially
thought as “medical problems”.15 A specific
question such as, “can you tell me what bothers
you the most?” can help the patient to bring up
their “hidden agenda”, and a truly thoughtful
physician will want to devote time to listening
sympathically to uncover their concerns and
offer reassurance.
Some patients, although having a clear
sickness, may not consult doctor earlier,
with an idea that their illness is trivial and
self-limiting. Although they may be worried
and afraid about the nature of their illness,
they delay consulting physician by seeking
reassurance from others to ease their anxiety,
which later leads to worsening of their illness.
Some patients seek physician’s advice
not to get cured but be defined as sick. Apart
from direct financial benefits such as medical
compensation, escape from court, legal or tax
matters, “sickness” may satisfy their emotional
needs, such as dependency, or an excuse to
avoid a stressful situation.
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Other factors, e.g. social class, income,
educational and ethnical status are important
determinants of patient’s belief in sickness.
Often family physicians need not take
past, family, or therapeutic histories as these
are well-known to them. This “continuing
care relationship” is one of the distinguishing
features of family practice.16,17
Patient as an Individual
While taking patients’ history, important
information can be gained by noticing their
tone of voice, facial expression, attitude, and
other aspects of their body language. One study
concludes that physicians may capture more
of their patients’ hidden emotional messages
in the consultation by increased awareness of
specific verbal characteristics and non-verbal
cues.18 These aspects—mental and physical
expressions—help in the evaluation of their
emotional status and their relationship to
their social, financial, family and personal
life style, which is of practical importance
in the management of patient as a whole. In
listening to the history, the physician discovers
not only something about the disease, but
also something about the patient who has the
disease.19
Clinical Process—Physical
Diagnosis
By the end of the history, the physician will have
established sufficient rapport with the patient,
so that the initiation of physical examination is
a comfortable and natural process.
Levels of concern and anxiety on the part
of the patient must be considered before
examination of the patient, and a general
explanation of the content and time required
for the physical examination must be briefly
explained to the patient. This will enhance
patient’s confidence and cooperation during
physical examination.
 68  Section 3: Clinical Approach
The physician, in general, should elicit
subtle as well as obvious physical findings
by four basic modes*—inspection (in some
situations, the diagnosis can be made by
observation alone – e.g. rash of herpes zoster,
acromegaly, Down’s syndrome. Parkinson’s
disease, Cushing’s syndrome, etc.), palpation,
percussion, auscultation, and use appropriate
instruments gently when indicated. However,
the most valuable instruments the doctor
brings to the physical examination are sharp
eyes, ears, fingers, and mind, a basic knowledge
of the human body, and a healthy curiosity.**
The mechanical gadgets and other hi-tech
tools extend these primary tools.
When sufficient time is available, a
complete examination may be done, unless
inappropriate to the clinical situation.
When hard pressed for time, physician
should develop the skill of concentrating on
relevant physical examination in the shortest
possible time.
The physician should know the range of
normal variations of physical findings, and also
alternative techniques capable of confirming
abnormal findings. For example, plantar reflex,
or Babinski sign. When this sign is equivocal or
unequivocal, other alternative signs, such as
Chaddock, or Gordon’s sign, are helpful to elicit
corticospinal dysfunction. Physician should be
able to integrate physical findings — normal or
abnormal — with the diagnostic hypothesis. For
example, tachycardia in an anxiety prone patient
could be normal, but resting tachycardia may
be a sign of hyperthyroidism in an otherwise
normal individual. Physician should also be
able to judge how often and to what extent a
physical examination should be repeated on a
given patient, as findings not present on initial
examination may appear subsequently.
Although a plethora of investigations are
readily available, the physician should always
do physical examination in detail because its
diagnostic accuracy of a disease is over 80%,
which is cost effective. 20-24 When ordering
investigations, the physician should always
weigh carefully the hazards and expenses
of any investigations. The question of risks
verses benefits concerns medical ethics as is
the question of cost verses benefits concerns
medical economics.
Sequence in Clinical Diagnosis
(Flow chart 8.1)
The findings of the clinical process discussed
above provide the physician two powerful
tools, namely patient’s historical data and
clues in the history, and signs from physical
examination, which together assist in the
diagnosis of over 80% of illnesses commonly
seen family practice. When the outcomes of
these two tools are linked to the physician’s
personal and previous knowledge of the
“family dynamics”*** of the patient,**** and
also the “accumulated knowledge” of
probabilities of the occurrence of specific
illness in the community, the physician can
arrive at a “hypothesis” (i.e. a pattern of data
suggesting a tentative clinical problem), which
can be applied to a particular clinical situation.
This hypothesis can be revised when further

*This approach may vary with different disciplines. A dermatologist may first inspect the skin lesion; a
surgeon may first prefer palpation; a cardiologist may first auscultate the cardia; and a hematologist may
rely heavily on investigations to make a diagnosis.
**“The eyes see, the ears hear, the hands feel, only what the mind knows.” said Chamberlain.
***That is the ways in which family members relate to one another, their communication, cooperation,
financial status, habits, illness, and other related life style factors.
****The family physician’s personal and previous knowledge and family dynamics is a component often
missing in speciality practice.

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 Chapter 8: The Spectrum of Clinical Diagnosis 69
Flow chart 8.1  Outline of sequence in clinical diagnosis

clinical data or results of the investigations
are obtained.
Thus, initial history, physical examination,
and routine investigations usually narrow
down the initial hypothesis to an intermediate
step—a “syndrome” (i.e. a combination of
symptoms and signs forming a recognizable
disease pattern).
Consider, e.g. a young patient with abrupt
onset of high fever, chills, headache, intense
body aches, joint and muscle pains, retro-
orbital pain, and skin rash. This symptom
pattern of fever, intense body aches and joint
pains, retro-orbital pain and rash is a classical
presentation of dengue fever (a flashback linked
to the accumulated knowledge), and therefore,
it is the most likely, tentative, or provisional
clinical “hypothesis”. The attending physician’s
knowledge that this patient recently travelled to
a region, in which the disease is known to occur
(a link to family dynamics), further strengthens
this clinical hypothesis, and helps to rule out
similar diseases, such as typhoid fever, malaria,
yellow fever, scarlet fever, meningococcemia,
and several others. The physician, based on
historical data and a “clue” of his personal
knowledge of travel history, has now ruled out
possibilities of other diseases, and has arrived

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 70  Section 3: Clinical Approach
at the intermediate clinical stage of “syndromic
diagnosis”, Further, lab work out, such as
coagulation profile, and ELISA essay for dengue
virus help to clinch the diagnosis of dengue fever,
and thus the physician can arrive at the “specific
diagnosis” of dengue fever.
If the first syndromic approach does not
explain the clinical picture, a second syndrome
or mechanism may need to be considered. In
some clinical situations, further procedures or
investigations may be indicated, but the question
of whether the test is likely to provide essential
information which will help management
of particular patient should be asked. In
such a perplexing situation it should also be
remembered that, if the symptoms and signs
do not suggest an immediate life-threatening
condition, the situation may resolve itself with
observation over a period of time. Further new
symptoms and signs may emerge, or results of
investigations, which were negative, may become
positive over time. Thus, “judicious delay”, also
known as “Wait on Event (WOE)”,25 can be an
extremely useful diagnostic tool. However, it
requires the knowledge of the potential causes,
and an awareness of what the delay in diagnosis
may mean to the management of the patient. A
serious, life-threatening disease will be therefore
ranked higher than probability would indicate.
For example, in an elderly, myocardial ischemia
will precede any other “probable” cause of chest
pain. Similarly, a disease which can be treated
and cured will be ranked higher than other
diseases with similar probability. For example,
acute appendicitis will top the list of any other
cause, such as non-specific mesenteric adenitis,
due may be the “probable” cause of acute pain
in the abdominal right iliac fossa.
Diagnosis in Family Practice
Diagnostic strategy recommended for family
physicians is similar to that in other medical
*As someone aptly states, “In many cases a GP has to deal with a first draft, whereas the consultant gets
the edited transcript.”
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specialities, but has special characteristics
appropriate to the unique features of family
practice.26,27 Some of these features are listed
in Table 8.5.
Because of the nature of family practice,
diagnosis is more frequently a model of
“working hypothesis”. The diagnosis, on many
occasions, is not as clear as when a patient first
presents to a specialists or hospital.* There are
a number of reasons for this:
™™ The family physician often deals with
undifferentiated clinical problems, i.e.
problems that have not previously been
assessed by a physician.
™™ The family physician often sees disease
in an early stage, before the full clinical
picture has developed. Since the sensitivity
and specificity of clinical data vary with the
stages of a disease, tests that are valuable in
family practice may be different from those
that are useful in hospital practice.
™™ The prevalence of disease in family practice
is very different from its prevalence in the
selected population of a hospital, clinic
or ward. Since the predictive value of
clinical data varies with the prevalence of
Table 8.5  Characteristics of family practice
• Type of illness often encountered:
– Minor, self-limited, or transient illness
– Illness with complex mixture of physical,
psychological, and social elements
– High incidence of illness often similar to that
in the community
• Stage of illness:
– Early stage of illness, often with subtle clues
– No previous physician’s evaluation
• Scope of patients and problems:
– All age groups
– All anatomic systems
– All types of etiopathogenesis
– High-volume practice
• Physician-patient relationship:
– Relationship with patients is continuous, and
extends beyond individual episodes of illness
– Awareness of family dynamics
 Chapter 8: The Spectrum of Clinical Diagnosis 71
a disease in a given population, the same
symptom, sign or test will have a different
predictive value in family practice from
that in hospital practice.
™™ Even after full assessment, a significant
proportion of problems cannot and do not
need to be diagnosed in the usual sense
of the term. Many clinical decisions have
therefore to be made without a precise
clinical diagnosis. Knowledge of the patient
as a whole encompassing physical, social,
and psychological aspects often plays a
major role in these decisions. Often the
most important task is to eliminate the
possibility of serious disease—a process
called “eliminative diagnosis”. In many
cases, therefore, the objectives of the family
physician are to sort patients into “binary
categories” (Flow chart 8.2).
Flow chart 8.2  Binary tree decision in family practice
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In view of these considerations, the
traditional pattern of diagnosis in terms of
a precise statement of pathophysiology as a
requirement for treatment is sometimes of
doubtful validity. The family physician’s duty
to protect his/her patients from risk, and to
relieve suffering will often mean that action
must be taken before a pathophysiological
diagnosis is established, or as part of the process
of establishing that diagnosis. To this end,
management decisions are made on the basis
of probability and investigations used with due
regard to their sensitivity and specificity. The
passage of time and the therapeutic trial are also
considered valid bases for arriving at diagnoses.
The plan of action will be negotiated with the
patient and his or her family, with an honest
presentation of probabilities so that they may
make an informed choice.
 72  Section 3: Clinical Approach
Finally, experience acquired at the bedside
during the course of professional life increases
knowledge, diagnostic skills and judgment.
These aspects need to be applied in the process
of clinical diagnosis and management of total
patient care.
The Differential Diagnosis
The construction of a differential diagnosis is
essential in planning the course of diagnostic
evaluation. Possible diseases should be
ranked in order of likelihood and according
to prevalence in the population. The impact
of this rank order list is determined by the
physician’s fund of knowledge, patient’s age,
sex, occupation, and lifestyle risk factors. A
disease cannot be diagnosed and treated unless
known and understood by the physician.
The axiom, common diseases present
commonly, and its converse, uncommon diseases
present uncommonly, should serve to focus the
physician’s attention on the importance of disease
prevalence when formulating a differential
diagnosis. However, physician must also realize
that an uncommon manifestation of a common
disease, rather than a common presentation
of an uncommon disease is not unusual in
clinical practice. Additionally, no matter how
contrary to the presentation, there should be
serious consideration given to those conditions
that are potentially life-threatening. Discarding
a diagnosis too early may ultimately jeopardize
patient care. Atypical chest pain in ischemic heart
diseases, cough and dyspnoea in pulmonary
embolism, fever and rash of meningococcemia
are examples of prompt diagnosis of an astute
physician, because disease process is lethal unless
diagnosed and treated early.
The mnemonic, “I’M VINDICATED”
which stands for: Iatrogenic, Metabolic,
Va s c u l a r, In f l a m mat i o n , Ne o p l a s m s,
Drugs (Doctor induced/toxins), Infection,
Congenital (hereditary), Autoimmune,
Trauma, Endocrine, Degenerative/Don’t know
(idiopathic), may be helpful in considering
the differential diagnosis in any patient. For
a given specific complaint, each category is
mentally perused for possible etiologies.
Changing Conceptions of Health,
Disease and Diagnosis28
As physicians, we approach our patients
and their problems within the framework
and culture of the modern, dominant
medical model—the “biomedical model”.
Biomedical models originate from Virchow’s
conclusion that all disease results from
cellular abnormalities. He stated that all
diseases involve changes in normal cells, i.e.
all pathology ultimately is cellular pathology.
Its history goes back to the birth of modern
science during the renaissance in the 14th
and 15th centuries, and it is often associated
with french philosopher and scientist Rene
Descartes’ view of the mind and the body as
separate systems.* It organizes and defines
the questions we ask, the information
we seek, the diagnostic and therapeutic
options, and ultimately the outcome of
our interventions.
The biomedical model sees the body as
functioning in a mechanical way, and sees illness
as the result of changes in physiological process
as a result of injury, chemical imbalances,
genetic defects, bacterial or viral infections, or
other physical causes. This view sees health

*The famous mind-body problem has its origins in Descartes’ conclusion that mind and body are really
distinct. The crux of the difficulty lies in the claim that the respective natures of mind and body are completely
different and, in some way, opposite from one another. On this account, the mind is an entirely immaterial
thing without any extension in it whatsoever; and, conversely, the body is an entirely material thing without
any thinking in it at all. (Web site- http://www.iep.utm.edu/descarte/#SH7b. Accessed on 08-11-2011).

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 Chapter 8: The Spectrum of Clinical Diagnosis 73
as the absence of illness (i.e. all illness is
secondary to disease), and would expect
effective treatments to be those that changed
the physical state of the body in such a way
as to correct the physical cause of illness. The
approach generally involves looking for a
single, very specific cause or cure for illness, i.e.
“reductionistic” view—it begins with a general
review of the body systems and progresses
toward a subsequent focus on a particular single
system most directly related to the presenting
symptom.
Although, this biomedical model has served
us well, no description of the diagnostic process
can overcome the requirement of the physician
to have a sound knowledge of normal body
structures and processes, and their disorders
in disease states, together with an awareness
of the modification of the features of disease
by social and psychological factors. With the
progressive urbanization of life, accompanied
by industrial and technogic revolutions,
humankind has seen the development of new
and very different adversities, which have
resulted in the emergence of a uniquely new
category of modern day aliments, particularly
stress related diseases, and those linked to
personal attitudes and lifestyle. Further, many
patients present with symptoms that are not
attributable to any underlying pathology
or disease, e.g. the so-called medically
unexplained symptoms. Patients with medically
unexplained symptoms—comprizing a
spectrum of disorders ranging from mild
transitory illness to chronic disorders with
severe disability—do not fit into the existing
framework of a biomedical model that tends
to focus on the exclusion of physical disease.
However, the exclusion of relevant physical
disease may not in itself cure the patient. He or
she may still feel ill and seek medical care, and
such patients do not receive a correct diagnosis
and undergo numerous fruitless investigations
and attempts at treatment.
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As the traditional Bio-medical model
of medicine is inefficient in addressing the
psychological, psychosocial, and spiritual
aspects that are the source of many
“unexplained” aliments often seen in
the contemporary primary care practice,
George Engel, in the 1970s, developed the
“Biopsychosocial model”—an expanded model
of diagnosis and treatment. Engel did not deny
that the mainstream of biomedical research had
fostered important advances in medicine, but
he criticized its excessively narrow (biomedical)
focus for leading clinicians to regard patients
as objects and for ignoring the possibility that
the subjective experience of the patient was
amenable to scientific study.29 This model
includes the psychological and psychosocial
factors that were excluded from the previous
model, while at the same time maintaining its
scientific approach. It does not look for single,
specific causes for illness, but sees health and
illness as resulting from the interacting effects
of events of very different types, including
biological, psychological, and social factors.
All of these are seen as systems that affect on
another and interact with one another to affect
individual health.
A Biopsychosocial Model
The medical community is becoming more
aware that attending to the psychosocial impact
of illness not only helps patients emotionally
but is also cost-effective. Psychosocial
intervention, especially in the chronically ill
can reduce healthcare utilization, days spent
in the hospital, disability, lost workdays, and
illness-associated morbidity and mortality.
The biopsychosocial model is both a
philosophy of clinical care and a practical
clinical guide. Philosophically, it is a way
of understanding how suffering, disease,
and illness are affected by multiple levels of
organization, from the societal to the molecular.
At the practical level, it is a way of understanding
 74  Section 3: Clinical Approach
Fig. 8.1  Integrated approach to health and disease
the patient’s subjective experience as an
essential contributor to accurate diagnosis,
health outcomes, and humane care.
Thus, the biopsychosocial model expands
the vision and reach of modern medicine to
respond to the changing needs and demands
of a diverse population of patients that must
be incorporated by every physician in his
diagnostic skills.
Conclusion
™™ In family practice the link between
symptoms and diseases is less robust.
™™ Family physicians utilize a problem-
solving approach unique to the demands
of family practice.
™™ For a family physician, clinical decision
making, with a course of action is more
important than a diagnostic label.
™™ The Biopsychosocial model strives to provide
a fuller understanding of the factors involved
in illness at the level of both the individual
and healthcare systems.
References
1. World Organization of National Colleges,
Academies and Academic Associations
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(WONCA), The European Definitions of
General Practice/Family Medicine, short
version, 2005.
2. Phillips WR, et al. The domain of family
practice: scope, role, and function. Fam Med.
2001; 33(4):273–7.
3. Kroenke K. Symptoms in medical patients: an
untended field. Am J Med 1992;92(1A):3S–6S.
[PMID: 1734731: Abstract].
4. Kisely S, et al. An international study
comparing the effect of medically explained
and unexplained somatic symptoms on
psychosocial outcome. J Psychosom Res, 2006;
60(2):125–30. [PMID: 16439264: Abstract].
5. Kroenke K, et al. Common symptoms in
ambulatory care: incidence, evaluation,
therapy, and outcome. Am J Med 1989;
86(3):262–6 [PMID: 2919607: Abstract].
6. World Organization of Fam doctors, WONCA.
The Role of GP/FP in health Care system – A
statement from WONCA, 1991.
7. Hertzler E. The Horse and Buggy Doctor. New
York, Harper, 1938.
8. Jagosh J, et al. The importance of physician
listening from the patients’ perspective:
Enhancing diagnosis, healing, and the doctor-
patient relationship. Patient Educ Couns.
2011. [Epub ahead of print], [PMID: 21334160:
Abstract].
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9. Harrison’s Principles of Internal Medicine,
Fauci, et al (Ed). 14th edn. 1997.p.1:2–3.
10. Lele RD. Clinical competence. In: The Clinical
approach:a companion for the practicing
doctor.Oxford University Press. 1997.pp.3–6.
11. Barsky AJ. Forgetting, fabricating, and
telescoping: the instability of the medical
history. Arch Intern Med, 2002;162(9):981–4.
[PMID: 11996606: Abstract].
12. Redelmeier DA, et al. Problems for clinical
judgement: 1. Eliciting an insightful history
of present illness. CMAJ. 2001;164(5):647–51.
[PMID: 112582: Free text].
13. Sandner-Kiesling A, et al. A chronic pain
patient: modern diagnosis and concept of
therapy. Psychiatr Danub. 2010;22(3):459–64.
[PMID: 20856193: Abstract].
14. Marlowe et al. ABC of mental health: Disorders
of personality. BMJ. 1997;315(7101):176–9.
15. Orient JM. The interview. In: Sapira’s Art and
Science of Bedside Diagnosis. Lippincott
Williams & Wilkins, 2nd edn. p.18
16. Tarrant C, et al. How important is personal care
in general practice? BMJ, 2003; 326(7402):1310.
[PMID: 12805168: Free PMC Article].
17. Schers H, et al. Continuity of care in general
practice: a survey of patients’ views. Br J Gen
Pract 2002;52(479):459–62. [PMID: 12051209:
Free PMC Article].
18. Steine S, et al. Words and language used
by patients when describing consultation
with general practitioners. Tidsskr Nor
Laegeforen. 2000;120(3):354–6. Norwegian.
[PMID: 10827528: Abstract].
19. Bikson K, et al. Psychosocial problems in
primary care: patient and provider perceptions.
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Soc Work Health Care, 2009;48(8):736–49.
[PMID: 20182986: Abstract].
20. Diamond GA, et al. Analysis of probability as an
aid in the clinical diagnosis of coronary-artery
disease. N Engl J Med, 1979;300(24):1350–
8[PMID: 440357: Abstract].
21. Shub C. Angina pectoris. Clinical strategies
in diagnosis. Postgrad Med. 1984;76(3):50–4,
59–63, 66. [PMID: 6473220: Abstract].
22. Wainner RS, et al. Reliability and diagnostic
accuracy of the clinical examination and
patient self-report measures for cervical
radiculopathy. Spine (Phila Pa 1976). 2003;
28(1):52–62. [PMID: 12544957: Abstract].
23. David S. Wade et al. Accuracy of Ultrasound in
the Diagnosis of Acute Appendicitis Compared
With the Surgeon’s Clinical Impression Arch
Surg. 1993;128(9):1039–46.
24. Salvarani C, et al. Is duplex ultrasonography
useful for the diagnosis of giant-cell arteritis?
Ann Intern Med, 2002;137(4):232–8. [PMID:
12186513: Abstract].
25. Longmore M et al. Oxford Handbook of Clinical
Medicine, 5th edn.: 8–9.
26. McWhinney I.R. Albert Wander Lecture. Proc
Roy Soc Med, 1972;65.
27. World Organization of Fam doctors, WONCA.
The Role of GP/FP in health Care system – A
statement from WONCA, 1991.
28. Dacher ES. A systems theory approach to an
expanded medical model: a challenge for
biomedicine. J Altern Complement Med. 1995;
1(2):187–96. [PMID: 9395613].
29. Borrell-Carrió F, et al. The biopsychosocial
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2(6):576–82. [PMID: 15576544: Free full text].
 9 INVESTIGATIONS:
GENERAL PRINCIPLES
“To under-investigate is bad. To over-investigate is worse.”
Introduction
Classically, the diagnostic process is based on
medical history, physical examination, and
investigations involving laboratory analysis.
These essential aspects, i.e. knowledge of the
patient’s history, key findings on examination,
appropriate investigation reports, and
physician’s fund of clinical knowledge
generally help the physician to define an
illness in a certain pattern of a recognized
clinical entity. Such a process is generally
labelled as “working or provisional diagnosis”
or a “hypothesis”. The working or provisional
diagnosis facilitates early disease management
while awaiting special or more definitive
studies, and may be changed or improved by
subsequent tests or repeat examinations or
sometimes by another physician.
However, this conventional approach of
diagnosis of a disease may be misleading
for many reasons. Many symptoms typical
of one condition are sometimes unusual
manifestations of another (i.e. a symptom can
mimic many disease patterns—both common
and uncommon). For example, an elderly
patient complaining of tiredness may have
anemia which may be due to some internal
malignancy, i.e. the patient’s symptom of
tiredness is not apparently due to anemia, but
it is secondary to malignancy. Similarly, the
cause of acute abdominal pain in a woman
could be due to an uncommon cause such as
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ruptured tubal pregnancy, and not due to a
common cause like acute appendicitis.
Further, apparently identical symptoms
may result from more than one etiopathology.
For example, fever with chills may be due
to malaria, cystitis, abscess, or pneumonia.
Likewise, a patient’s icterus may be due to
hepatocellular or obstructive etiology.
It is also a fact that many physical
findings, such as elevated blood pressure,
and abnormal reports of investigations, such
as hyperlipidemia and impaired glucose
tolerance indicate “risk factors” rather than
symptoms or disease. Recent evidence
shows that interventions which modify “risk
factors” have positive effects on subsequent
development of morbidity and mortality. This
can only be achieved by means of “screening”
investigations in a specific asymptomatic
population.
Thus, the symptoms may not co-relate
with common illness; they differ from patient
to patient, and are further influenced by
age, gender, ethnicity, family history, socio-
demographic and life-style factors. In spite of
these variables, it is essential for physicians
to analyze symptoms and arrive at a working
diagnosis and treat the patient’s illness.
Refining Clinical Diagnosis
Although it has been the experience of family
physicians that, within primary care, over 80%
 Chapter 9: Investigations: General Principles 77
of the diagnosis can be made on the basis of
robust history and physical examination, 1
there is a need in the remaining subset of
patients, in whom investigations are necessary
to confirm the diagnosis. For example,
patient’s symptoms of polyuria, polyphagia,
and polydipsia indicate diabetes mellitus;
however, it’s the investigations showing
abnormal glucose tolerance that will confirm
the diagnosis of diabetes mellitus. Similarly,
elevated TSH values confirm hypothyroidism.
Sometimes, physicians may have to decide
on invasive tests when non-invasive tests
are unhelpful or equivocal. For example, in a
patient with cough, and chest radiograph with
evidence of pulmonary TB, but sputum smear
being negative for AFB on three occasions.
The sputum does not show malignant cells
on cytological examination. When faced with
such an uncertain situation, the physician may
have to resort to bronchoscopy to ascertain the
diagnosis of pulmonary TB or otherwise before
starting specific medications.
It is therefore obvious that, along with
the conventional bed-side methods of
diagnosis, i.e. historical data, physical findings,
investigations are essential in refining the
clinical diagnosis and thus assist in the
management of the patient’s illness.
The Reason for the Test
Physicians have the responsibility (clinical and
economic) to be very discerning and selective
in selecting an investigation. The questions,
which should be asked in decision-making
include:
™™ Is this investigation necessary? Physicians
should understand the limitations of the
investigations they employ. Unintelligent
use of laboratory tests is wasteful of time
*This is popularly called as ‘wild-goose chase’ indulged by physicians with ‘zealous over-testing syndrome’
disorder. The ‘goose’ is never caught; the patient (who was previously well) is now unhealthy, because
of worry caused by false-positive results, and the physician is frustrated (in not being able to diagnose
something that is nor there).
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and money, and can increase anxiety and
concern to the person’s health.*
™™ Will it change my management? If the answer
is “yes”, the next question to be answered is,”
Can the same information be obtained by
another cheaper, or quicker, or less invasive
procedure?” if the answer is “yes”, then
additional test-evaluation must be done.2
Richard Asher, a critical medical writer,
has said: “It is in the ordering of laboratory
or radiological investigations that rational
thinking is so necessary. It is a salutary exercise
in mental discipline to catechize oneself when
ordering any medical investigation”. He listed
the following questions a physician should ask
before requesting an investigation:
™™ Why am I ordering this test?
™™ What am I going to look for in the result?
™™ If I find it, will it affect my diagnosis?
™™ How will it affect my management of the
case?
™™ Will it ultimately benefit the patient?
In general, investigations should be
performed only when the following criteria
are satisfied:
™™ The consequence of the result of the
investigation could not be obtained in a
cost effective, less invasive method, e.g.
taking a better history or using time.
™™ The risks of the investigation should relate
to the value of the information likely to be
gained.
™™ The result will directly assist in the diagno­
sis, or have an effect on the subsequent
management.
Analytical Errors
A wealth of new investigations has become
essential to the practice of modern medicine.
 78  Section 3: Clinical Approach
With the availability of vast number of
sophisticated laboratory tests, the physicians’
dependence on them continues to grow. It
is essential, however, to bear in mind the
limitations of such procedures, which by virtue
of their impersonal quality and complexity
often gain an aura of authority, regardless
of the fallibility of the tests themselves, the
instruments used in the tests, and the individual
performing or interpreting them.3 Pre-analytic,
analytic and post-analytic errors (Fig. 9.1)4
such as labelling, incorrect techniques, sample
contamination, insufficient amount of blood
collected to the actual requirement of a test
(the anti-coagulant to blood ratio), improper
storage and transportation of samples, etc.
are inevitable. However, an appreciation of
pre-analytical errors (Table 9.1), which may
influence test results independent of the
laboratory, is often lacking.5 Moreover, reports
of various investigations and laboratory
data do not relieve the physician from the
responsibility of careful observation and
study of the patient. One must know which
abnormalities are sought, why they might
be present, and what one will do if they are
present. The ability to make effective use of
Fig. 9.1  Laboratory testing cycle
Source:  Frank H. Wians, Jr.Clinical Laboratory Tests: Which, Why, and
What Do The Results Mean? Lab Medicine. 2009;40:105-13.
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the investigations should be developed as
carefully as other clinical skills required for
good medical practice. A thoughtful and cost-
effective use of investigations is the hallmark
of clinical competence.
Interpretation of Tests (Table 9.3)
An ideal investigation or a test would establish
the presence or absence of disease in every
individual who is tested.
If a test gives a positive result in all patients
having a disease, the “sensitivity” of the test, (i.e.
positive in disease) is described as 100%.
If a test gives a negative result in all patients
not suffering from a disease, the “specificity”
of the test (i.e. negative in health) is described
as 100%
Unfortunately no test has these ideal
attributes, i.e. 100% sensitive and 100%
specific. In reality, tests, instruments, and
laboratory operations all contribute to small
but measurable variations in results.
Hence it is desirable to understand the
statistical terms (Table 9.2), namely sensitivity,
specificity, positive predictive value, and
negative predictive value used in evaluating
the diagnostic performance of the test results.
 Chapter 9: Investigations: General Principles 79

Sensitivity It refers to its ability to identify persons with

Sensitivity (i.e. positive in disease) relates to
the test’s ability to identify positive results.*
TABLE 9.1  Pre-analytical factors influencing test results
• Biological variables:
– Influence of cyclical circadian hormone
levels, e.g. cortisone, catecholamines,
Pituitary hormones, melatonin, renin,
aldosterone, etc.
– Pregnancy, menstruation status
• Patient related variables:
– Physical exercise – its intensity and duration
– Postural changes – supine and standing
– Diet – pre-and post-prandial status
– Beverages and alcohol consumption
– Stress
– Drug administration
– Comorbid illness
• Blood collection variables:
– Incorrect patient identification
– In correct source of specimen
– Incorrectcollectiontimeforspecificanalytes
– Incorrect sample collection technique
– Incorrect tube or container
– Inadequate volume
– Incorrect preservative
– Sample mix up
• Post-blood collection variables:
– Improper transport conditions
– Sample processing and storage
a certain disease among a group of people
all of whom have that particular disease, i.e.
true positive. When the test fails to identify
persons having the disease, the result is called
“false negative”, i.e. persons with a disease are
incorrectly identified as healthy.
A highly sensitive test detects most of the
people with a certain disease, i.e. true positive,
and has few false negative. A test that is 95%
sensitive means the test correctly identifies
95 having the disease, i.e. true positive, out of
100 with disease; the remaining 5 persons with
TABLE 9.2  Statistical terms of tests
•  ensitivity: The ability of a test to correctly
S
identify those with the disease (true positive
rate) specificity: The ability of the test to correctly
identify those without the disease (true negative
rate)
• T rue positive: Diseased people correctly
diagnosed as having a disease
• False positive: Healthy people incorrectly
identified as having a disease
• True negative: Healthy people correctly identified
as healthy
• False negative: Diseased people incorrectly
identified as healthy

TABLE 9.3  Interpretation of diagnostic tests

Feature of the test Alternative name Questions that the feature examines
Sensitivity Positive in disease/true How good is this test at identifying people who have the
positive rate disease?
Helpful to “exclude” a disease
Specificity Negative in health/true How good is this test at identifying people who do not
negative rate have the disease?
Helpful to “confirm” a disease
Positive predictive value Post-test probability of a If a person tests positive, what is the probability that
positive test he/she has the disease?
Negative predictive value Post-test probability of a If a person tests negative, what is the probability that
negative test he/she does not have the disease?
Accuracy Gold standard test Highest percentage of all results—both true positive
and true negative combined together—has given the
correct results

*Sensitivity: “I know my patient has the disease. What is the chance that the test will show that my patient
has it?”

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 80  Section 3: Clinical Approach
disease are incorrectly identified as healthy, or
not having that disease, i.e. false negative.*
A test with high sensitivity is useful to
exclude a diagnosis because a highly sensitive
test will render few results that are falsely
negative. For example, to exclude infection
with HIV virus, a physician may choose a
highly sensitive test such as ELISA assay to
test for HIV antibodies. Though this test has a
high sensitivity for detecting HIV antibodies,
it is not sufficiently specific for making a firm
diagnosis. Thus, if ELISA assay is positive, it
is repeated. Confirmation of the diagnosis of
HIV antibody positively requires Western Blot,
or an equivalent specific test, to exclude the
possibility of a false-positive ELISA assay.
Specificity
Specificity (i.e. negative in health) relates to the
test’s ability to identify negative results.** It refers
to its ability to identify persons who do not have
a disease. A test that is 95% specific means it
correctly identifies 95 not having the disease,
i.e. true negative, out of 100 normal people; the
remaining 5 are false positive, i.e. normal persons
incorrectly identified as unhealthy.***
A test for high specificity is useful to confirm
a diagnosis, because a highly specific test will
have few results that are falsely positive. For
example, the conventional twelve lead ECG
criteria to diagnose acute myocardial infarction,
which include the presence of new ST-segment
elevations exceeding 1.0 mm in two or more
electrically contiguous leads in patients who
present with prolonged chest pain; this is
consistent with myocardial infarction and is
sufficiently specific, i.e. sufficiently unlikely to
be a false positive result, on the basis of which
the patient can be recommended hospital
ICU admission for thrombolysis or emergent
coronary angioplasty. However, this test is
not sensitive, because if admission to hospital
were restricted to the above ECG criteria alone,
almost 50% of MI patients, who may have normal
ECG findings in the presence of myocardial
infarctions would be missed.6
Predictive Value
Predictive value of the test is the probability
of having the disease, given the results of
a test. Predictive value is an answer to the
question: If a patient’s test result is positive,
what are the chances of that patient actually
having the disease? It reflects the diagnostic
power of the test. It is determined by the
sensitivity and specificity of the test and the
prevalence of disease in the population
being tested (Prevalence is defined as the
proportion of persons in a defined population
at a given point in time with the condition in
question). The more prevalent a disease in
a given population, the more accurate will
be the predictive value of a positive test. For
example, in a population with high incidence
of malaria, the positive predictive value of the
malaria antigen rapid diagnostic tests will
be very high. Thus, Positive predictive value
(PPV)**** is the probability that a patient with a
positive (abnormal) test result actually has the
disease. Negative predictive value (NPV)*****

*Patient with ‘false-negative’ test result may ignore the signs and symptoms and may postpone treatment,
which may prove detrimental, if not diagnosed early.
**Specificity: “I know my patient doesn’t have the disease. What is the chance that the test will show that
my patient doesn’t have it?”
***Patient with ‘false-positive’ test result may be subjected to further diagnostic tests, at the risk of causing
anxiety and expense to the patient, who was otherwise in normal health.
****PPV: “I got a positive test result of my patient. What is the chance that my patient actually has the
disease?”
*****NPV: “I got a negative test result of my patient. What is the chance that my patient actually doesn’t
have the disease?”

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 Chapter 9: Investigations: General Principles 81
is the probability that a person with a negative
(normal) test result is truly free of disease.
It follows that careful selection of patients
for study will increase the usefulness of a
positive test. In patients with polyarteritis
and morning stiffness in joints will yield more
positive test results for rheumatoid factor than
in those with headache.
Combination of Tests
Two or more tests can be used in combination
to enhance the sensitivity and specificity of a
test. For example, the evidence of ischemia in
an ECG tracing in a patient with precordial pain
is substantiated further with positive cardiac
enzyme values. To further enhance the diagnosis
of cardiac ischemia, both ECG and cardiac
enzymes are monitored at periodic intervals.
Slightly Abnormal Results
The slightly abnormal result requires careful
assessment:
™™ The test should be repeated, because
human and technical errors are possible.
™™ Test report may be completely irrelevant to
the clinical situation. For example, slightly
raised aspartate transaminase (i.e. SGOT)
concentration in a patient with chest pain.
™™ Test report may suggest some pathology not
previously suspected. For example, slightly
raised aspartate transaminase (i.e. SGOT)
concentration in an unsuspected alcoholic.
™™ Alternative tests may confirm or refute the
suggested information; e.g. elevated values
of CPK-MB may confirm that slightly raised
values of aspartate transaminase (i.e.
SGOT) were related to myocardial injury.
Importance of Chronological Data
Review of previous clinical and investigation
reports is as important as collecting new
data. In many clinical situations, serial tests
or information may be required to monitor
the response to treatment and to plan future
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management; e.g. a single report of Hb 12.5 g%
in a patient, whose previous documented
Hb levels were 14.5 g% raises the possibility
of recent blood loss due to some etiology;
recording of body weight of a patient at one
single point is not as informative as weight gain
or loss over a period of time; the interpretation
of a ‘q’ wave in a recent ECG would be
drastically altered if the previous ECG a year
back also shows the same pattern.
Right Choice of Test
Depending on the cumulative evidence of test
sensitivity, specificity, and predictive values,
following general guidelines may be outlined
to select tests in the context of specific disease.
In general, highly sensitive tests are useful in
“excluding” a diagnosis, and highly specific
tests are useful in “confirming” a diagnosis.
™™ Tests with highest sensitivity—usually
indicated when the disease is:
ƒƒ Serious and should not be missed.
ƒƒ Prognosis is good.
ƒƒ False positive results do not cause
serious physical, psychological, or
economical harm to the patient,
e.g. infectious diseases, endocrine
disorders, nutritional disorders, etc.
ƒƒ Test examples—Gram stain and sputum
culture in a patient with pneumonia;
upper GI endoscopy in a patient with
peptic ulcer disease.
™™ Tests with highest specificity—usually
indicated when the disease is:
ƒƒ Serious and should not be missed.
ƒƒ Prognosis is poor.
ƒƒ False positive results can cause serious
physical, psychological, social, and
economical harm to the patient, e.g.—
malignancy, HIV infection, etc.
ƒƒ Test examples—Western blot test in
a patient with HIV infection; lymph
node biopsy in a patient with Hodgkin’s
disease.
 82  Section 3: Clinical Approach
™™ Tests with highest efficiency (gold
standard) tests—are indicated when the
disease is:
ƒƒ Serious and should not be missed
ƒƒ Prognosis is better
ƒƒ Both false positive and false negative
results are equally serious and
damaging. For example, both acute
myocardial infarction and unstable
angina are potentially fatal but
treatable conditions. Equal harm can
be done if the diagnosis is missed
(i.e. false negative report), or if the
diagnosis is made wrongly (i.e. false
positive report), and anticoagulant or
thrombolytic therapy is administered.
Therefore, physician opts for tests with
maximum efficiency prediction value,
like coronary angiography.
Gold Standard Tests
The results of gold standard tests or procedures
define the true disease state of the patient.
These tests have sensitivity of 100% (it identifies
all individuals with a disease process; it does
not have any false-negative results; i.e. they
are all true positive) and a specificity of 100%
(it does not falsely identify someone with a
condition that does not have the condition; it
does not have any false-positive results; i.e. they
are all true negative). Thus, these tests have
“highest efficiency”, i.e. highest percentage of
true positive and true negative results. Some
examples are: coronary angiography and radio
nuclide tests for myocardial function, necrosis,
and its viability; pulmonary arteriography in
pulmonary embolism; fasting and 2 hours
post-prandial plasma glucose values to
diagnose diabetes mellitus; HbA1C estimation
in monitoring diabetes control; and culture
techniques for M. tuberculosis from specimens
like sputum, CSF, pleural aspiration. However,
for many disease states such gold standard
tests either do not exist, or are very difficult and
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expensive, or may take too long for the results
of the test to be available to be clinically useful.
With the advent of modern imaging
technology, there appears to be a paradigm
shift in the concept of gold standard tests. For
example, conventional coronary angiography,
although an undisputed gold standard in
coronary lumenography, involves a small but
serious risk in the procedure, the cost, and the
necessary radiation dose, which have triggered
the development of non invasive alternatives
such as electron-beam computed tomography,
multi-slice computed tomography, and
magnetic resonance coronary angiography.
Evolution in these techniques and increase
in sensitivity and specificity have been clearly
seen in all imaging modalities, thus increasing
the clinical relevance and the ability to
replace conventional coronary angiography.7
Similarly, non-invasive MR angiography
using turbo-FLASH technique has superior
sensitivity and specificity as compared to the
conventional gold standard aortogram for
patients with advanced aortoiliac disease.8
Who the Investigation for: Patient
or Doctor?
Investigations serve two prime functions
of diagnosis and management. In addition,
it’s common in present practice to see
investigations used to “reassure the patient”.
Often, physicians assume that the patient
will be reassured by a negative test, such as a
skull X-ray to reassure the patient that there
is no brain tumor. However, it is important
for the doctor to consider whether or not
the patient will be reassured by such action.
Instead, it is better to find out what the issues
is that actually concern the patient and deal
with those emphatically. As a British Medical
journal editorial puts it, “Unless their true fears
are addressed, diagnostic tests may leave them
more anxious than before”.1,9
 Chapter 9: Investigations: General Principles 83
Conclusion
In routine family practice, an efficiently
compiled history and clinical examination
is usually adequate for most cases to be
diagnosed.
The issues of cost, potential risk, and
probability-related limitations of diagnostic
tests provide a strong basis for selectivity in
the use of diagnostic tests in family practice.
The need for investigation comes under the
following circumstances:
™™ The clinical findings do not fit in with
a routine disease pattern. Such cases
with multiple diagnostic possibilities
will need confirmation with tests. A
common example would be pyrexia of
undetermined aetiology.
™™ The diagnosis is common and apparent,
but needs investigatory work up since it
needs specific therapy for specific duration,
like malaria, typhoid, and tuberculosis.
Inadequate therapy leads to relapse and
complications.
™™ Less common illness, usually chronic
conditions, like endocrinal abnormalities,
resistant hypertension, congestive heart
failure, nephrotic syndrome, neurological
deficits, rheumatological disorders, and
many others obviously require a complete
work up. Unless family physician feels
confident to treat them adequately
by himself, it is good practice to leave
investigations to the specialist. The patient
is saved from unnecessary expenditure in
duplicating investigations.
In summary, physicians are faced with a
large, often bewildering array of potentially
useful investigations from which to choose as
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they deal with individual patient. However,
you can not judge a physician by the quantity
of investigations they use but by the quality of
use. The intelligent and cost-effective practice
of medicine consists of selecting those most
appropriate to a particular patient and clinical
situation. Laboratory tests should be hypothesis-
directed, and not merely “fishing nets”.
References
1. Physician Assistant profession. Web site -
http://www.nlm.nih.gov/medlineplus/ency/
article/001935.htm Accessed on 09-11-2011.
2. Stephenson Anne. A T B of General practice,
Arnold. 1998.pp.54.
3. Harrison’s Prin. of Int. Med. 14th ed. Vol. I, p.2–3.
4. Frank H. Wians, Jr.Clinical Laboratory Tests:
Which, Why, and What Do The Results Mean?
Lab Medicine. 2009;40:105–13.
5. Sciacovelli L, et al. The IFCC Working Group
on laboratory errors and patient safety. Clin
Chim Acta. 2009;404(1):79–85. Epub 2009 Mar
26. [PMID: 19328194: Abstract].
6. Kabakci G, et al. The diagnostic value of 12-lead
electrocardiogram in predicting infarct-related
artery and right ventricular involvement in
acute inferior myocardial infarction. Ann
Noninvasive Electrocardiol. 2001;6(3):229–35.
[PMID: 11466142: Abstract].
7. van Ooijen PM, et al. Noninvasive coronary
imaging: CT versus MR.Herz. 2003;28(2):143–9.
[PMID: 12669228: Abstract].
8. Sivananthan UM, et al. Fast magnetic resonance
angiography using turbo-FLASH sequences in
advanced aortoiliac disease. Br J Radiol, 1993;
66(792):1103–10. [PMID: 8293253: Abstract].
9. Fitzpatrick R. Telling patients there is nothing
wrong. BMJ, 1996;313(7053):311–2. [PMCID:
PMC2351770].
 4
Section

The Practice of
Family Medicine
™™ Communication Skills
™™ Rapid Access to Improving Communication Skills
™™ The Consultation
™™ The Physician-Patient Relationship
™™ Balint Group
™™ Designing a Patient-friendly Practice
™™ Counseling Skills
™™ Patient-centered Care
™™ The Team Approach
™™ Leadership
™™ Addressing Medical Errors
™™ Medical Records
™™ The Difficult Patient
™™ Medical Professionalism

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mebooksfree.com
 10 COMMUNICATION SKILLS
“Think like a wise man but communicate in the language of the people.”
Introduction
The patient-physician communication is
an integral part of clinical practice, and
continues to be the most important part
of patient-physician interaction. Even
when patients have appropriate access to
medical services, they also need effective
and empathic communication as an essential
part of their treatment. When done well, such
communication produces therapeutic effect
for the patient.1
Communication as a Core
Competency
However, the ability to communicate the right
message to the right people at the right time
can present a challenge, especially in today’s
environment of information overload due to
technologically advanced communicating
systems. 2,3 Presently, we have powerful
high-tech gadgets like pagers, voice-mail,
e-mail, fax, cell phones, personal digital
assistants, laptops, video conference facilities,
and the internet chat rooms which have
made communication faster and easier—just
about to anyone, anywhere, and at any time.
But the question frequently asked is—are
we communicating any better? Dr Mark
Lipkin Jr, director of the division of primary
care at New York University, and principal
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—William B. Yeats
investigator in the Macy Institute of Health
Communication, in his 4 year effort that
was launched in 1999 to strengthen the
communication skills of physicians states:
“Doctor-patient communication is the most
critical element of day-in, day-out medical
care, yet its been seriously neglected in medical
education. Today, the field of physician-patient
communication has grown from a period in
which this was taught charismatically, meaning
‘do what I do, and you will be great’, to a period
in which people are taught empirically, using
methods that have been tested and shown to
be of value.”4 Moreover, in the present complex
world of physician-patient relationship,
communication is emerging as a priority. The
Task Force on Competence of the American
Council on Graduate Medical Education, and
the American Board of Medical Specialities
identified interpersonal and communication
skills as one of the six areas in which physicians
need to demonstrate competence; the other
five areas being—medical knowledge,
patient care, professionalism, practice-
based learning and improvement, and
systems-based practice. 2 The National
Board of Medical Examiners, Federation of
State Medical Boards, and the Educational
Commission for Foreign Medical Graduates
have proposed an examination between the
third and fourth year of medical school that
 88  Section 4: The Practice of Family Medicine
“requires students to demonstrate they can
gather information from patients, perform
a physical examination, and communicate
their findings to patients and colleagues,”
using standardized patients.5 Besides, training
in patient-physician communication is now
objectively evaluated as a core competency
in various accreditation settings. 6 The
published literature also expresses belief in
the essential role of communication. “It has
long been recognized that difficulties in the
effective delivery of health care can arise
from problems in communication between
patient and provider rather than from any
failing in the technical aspects of medical
care. Improvements in provider-patient
communication can have beneficial effects
on health outcomes”. 3 Controlled studies
validate that good doctors communicate
effectively with patients; they identify patients’
problems more accurately, and patients are
more satisfied with the care they receive. But
what are the necessary communication skills
and how can doctors acquire them?7,8 Even
if doctors have the appropriate skills, they
may not use them because they are worried
that their colleagues may not give sufficient
practical and emotional support, if needed.9
Definition
Communication can be defined as, “the
successful passage of message from one
person to another. It is the art of imparting
knowledge, or exchanging thoughts, feelings,
and ideas by speech, writing, and gestures”.
Communication skills, which are funda­
mental to consulting skills, are the key to the
effectiveness of the doctor as a professional.
Based on this, a sound and lasting doctor-
patient relationship is created that ultimately
helps in the diagnosis (physical, social, and
emotional) and management of the patient.
*Mnemonic “ MART “
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The important principles facilitating
communication process are:*
™™ The Message: This needs to be clear,
correct, concise, and complete (i.e. 4 Cs).
™™ The Attitudes: Both the communicator and
the recipient (i.e. patient and physician)
should be genuinely concerned about
each other.
™™ The Rapport between the patient and
the physician: An atmosphere of respect,
warmth, and friendliness enhances good
communication.
™™ The Time factor: One should be unhurried,
calm and relaxed while conducting an
interview.
Importance of Effective
Communication
Effective communication typically is one of the
most important factors that patients consider
in selecting a physician and in gauging their
ongoing satisfaction with that physician.
When physicians use communication skills
effectively, both the physicians and their patients
benefit.6 Firstly, physicians can identify their
patient’s problems more accurately. Secondly,
patients are more satisfied with their physician’s
care, leading to better understanding of their
problems, investigations, and treatment options.
Thirdly, patients are more likely to adhere to
treatment and to follow advice on behaviour
change, such as food habits and physical exercise.
Fourthly, patients’ distress and their vulnerability
to anxiety and depression are lessened. Finally,
good communication skills help in the better
outcome in medicolegal issues. A growing body
of evidence suggests that the qualities of caring
and concern exhibited by physicians make a
difference in healthcare outcomes—the most
important reason patients with a bad outcome
decide to sue their physicians for malpractice
is not a lapse in the quality of care or medical

negligence, but how the physicians talks to
their patients and respond to their emotional
needs.10-13
Key Tasks in Communication with
Patients
These can be summarized as rule of five vowels
—“AEIOU”:
™™ Audition: Listening and eliciting patient’s
main problems; an important rule for
interviewing is to listen more, talk less, and
interrupt infrequently.
™™ Evaluation: Sorting out relevant from
irrelevant data; tailoring information to
what patients’ want to know, and checking
their understanding.
™™ Inquiry: Probing significant areas requiring
more clarification; especially the physical,
emotional, and social impact of the
patient’s problems on them and their
families.
™™ Observation: Emphasizes the importance
of observing non-verbal communication
while eliciting the patient’s reactions to the
information given to their main concerns.
™™ Understanding: Refers to understanding
patients’ concerns and apprehensions, and
discussing treatment options, so that they
understand the implications and advice
about changes in lifestyle.
Key Communication Skills Needed
to Perform Key Tasks7
Eliciting Patients’ Problems and
Concerns
Open-ended Questions and Body
Language (see below)
A cardinal principle of interviewing is to
permit patients to express their story in their
own words. Always talk to the patients in the
language they understand, the vocabulary
they use, avoiding long monologues, and
keeping the statements short with clear,
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Chapter 10: Communication Skills 89
simple explanation. While speaking with the
patient, physicians must determine not only
the main medical problems, but also how
patients feel toward their illness, what they
are going through; not only their pain and
discomfort, but how the illness has affected
them, their reaction to it, and what impact has
it had on their families, occupation, and social
life. Encourage patients to be exact about the
sequence in which their problems occurred;
ask for dates of key events, and about their
perceptions and feelings. This helps patients
to recall their experiences, feel understood,
and cope with their problems.
Careful observation of non-verbal clues
such as patient’s facial expressions as well
as body movements may provide valuable
information. The physician’s body language
such as a smile, nod, and silence encourage
patients to continue speaking.
Eye Contact
Establish eye contact at the beginning of the
consultation and maintain it at reasonable
intervals to show interest. However, prolonged
eye contact, or staring, can be offensive. Lack
of eye contact may be interpreted as a lack of
concern.
Active Listening and Reflecting
Active listening requires staying focused on
what the patient is saying, i.e. paying attention
without distractions, maintaining eye contact,
clarifying through reflecting what is heard
(this involves verbally using similar words
or rephrasing to express back to the patient
what was understood about the content of
his message; the intension is to understand
and accept what is said), showing empathy by
identifying with their feelings, and listening
with an open mind in order to understand
patient’s point of view.
During the interview, attention should
be more on what the patient is saying, and
 90  Section 4: The Practice of Family Medicine
less on written words. While taking notes, the
physician cannot observe the facial expressions
and body language that are important to the
patient’s history. One may jot down important
points rather than taking down extensive notes
while interviewing the patient.
Summarize
Summarizing information to show patients
they have been heard, and gives them an
opportunity to correct any misunderstandings;
e.g. “I’d like to get this clear... am I right?”; “Tell
me if I’ve got this clear....”; “Let’s just recap....
have I missed anything out?”
Inquire about the social and psychological
impact of important illnesses or problems of
the patients and families; e.g. “Do you have any
specific worries about....”; “Is there anybody
else you know who has had this problem?”;
“I’m sorry to press you, but what was really on
your mind....?”; this shows patients that you
are interested in their psychosocial well-being,
and their families.
Giving Information
Ask patients what information they would like,
and prioritize their information needs, so that
important needs can be dealt with first if time
is short. (“What’s the first thing you’d like to
discuss…?”; “What’s the one most troubling
you…?”; “Which one shall we tackle or focus
on first?”; “Which is the one most important
to you?”).
Avoid too many long sentences or medical
terms. Present information by category, e.g.
risk factors, diagnostic possibilities, treatment
options, etc. Check what patients consider
might be wrong and how those beliefs have
affected them. Provide information in a
slow and deliberate fashion. Check that the
*Some authentic web sites include: http://www.cdc.gov/; http://familydoctor.org/online/famdocen/home.
html; http://www.healthfinder.gov/; http://www.mlanet.org/resources/medspeak/index.html
**See chapter 30 –Communicating bad news. - p. 295).
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patient has understood before moving on.
With complex illnesses or treatments, such as
congestive heart failure, rheumatoid arthritis,
psychiatric disorders, etc., check if the patients
would like additional information, which may
be provided in customized written format, or in
the form of hand outs, or that can be accessed
from many internet web sites providing patient
information resources.*
Discussing Treatment Options
Patients should be properly informed of
treatment options, and also ascertain if they
want to be involved in decision process.
Patients who take part in decision-making
are more likely to adhere to treatment plans.
Patient’s views and beliefs about lifestyle
changes are also important aspects to be
evaluated, because although physicians have
ideas about what each patient ought to do to
benefit from health behavior changes (e.g. in
the secondary prevention of stroke, coronary
heart disease), they must respect patient’s
ultimate right to choose the course of action.
Being Supportive
Use empathy to show that you have some sense
of how the patient is feeling, e.g. an expression
such as, “The experiences you describe during
your mother’s illness sound devastating”; or, “I
can understand how hard it is to cope up these
problems you are facing due to this illness”; or
“I can see that you are frustrated by the lack
of improvement in your symptoms”. You may
also express to patients your impressions about
how they are feeling, e.g. “You say you are
coping well, but I get the impression you are
struggling with this treatment”. Even if the guess
is incorrect, it shows patients that you are trying
to further your understanding of their problems.

Communication Types
Communication is of two types—verbal and
non-verbal14
Verbal Communication (Fig. 10.1)
Verbal communication is when persons put
across their message by speaking; its impact and
significance varies with the tone, pitch, timber,
and speed of the voice with which persons speak.
™™ What you say? Always say the truth, e.g. if
your injection has resulted in an injection
abscess, admit it and tell the patient that it
can happen with anyone. It may not help
you immediately, but over a period of time
you will build a reputation, and the patients
will respect your word. Also, how long
can you hide the truth—there are enough
doctors out there waiting to catch your lie.
™™ How you say it? This point becomes
important when you have to break bad
news.** You have to be subtle and approach
the main point without beating round the
bush. Patients are smart and they know
something is coming up, and suspense is
the last thing wanted then. At times you
may feel that you are very close to the
patient and you can crack jokes at their
expense, but be careful—it may back fire!
™™ To whom do you say it? Always tell a
responsible person—mostly head of
the family. In case the matter concerns
the patient, talk directly, and if needed,
possibly involve the spouse, and/or an
elderly of the family. Never tell important
Fig. 10.1  Verbal skills
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Chapter 10: Communication Skills 91
things to neighbors or other relatives even
if you feel they are very close.
™™ When do you say it? There is always a right
time to say something. If you have taken
the concerned person away from everyone
else, wait for the right occasion. This way
you are telling all and sundry that there is
something that can’t be told to everyone.
While imparting health education, give it
when the patient needs it, e.g. hazards of
smoking in a patient with cough; or if the
patient has come for treatment of piles, he
will be attentive if you talk of hazards of
constipation.
™™ What you should not say? As a physician
you are bound by professional secrecy.
At times you may have to hide things
from members of the family, e.g. you may
discover that the patient smokes. By not
telling the parents, you may win over a
patient, but that doesn’t mean you should
not admonish the patient when alone.
At times what you do not say can have
detrimental effects on practice, e.g. while
referring a case of tetanus or acute MI to
the hospital, you must tell the family about
the likelihood of a bad prognosis, or even
the fact that the patient may not reach the
hospital. You may not say it bluntly but can
say, “Patient is critical, they should hurry
and shift him soon as every minute counts”.
Where Verbal Communication is
Helpful?
™™ History: To get proper history, patients will
not hide anything if they are comfortable
and trust their physicians.
™™ Investigations: Why is particular investi­
gation required; more so, if they are
invasive and expensive.
™™ Management: To explain their problems
and solutions, and why hospitalization is
essential.
 92  Section 4: The Practice of Family Medicine
™™ Prognosis: To convince patients that their
disease may take longer to treat and not
that your treatment is ineffective.
™™ Compliance: To convince patients to take
treatment for long periods (as in Koch’s) or
at times for life (as in HT, IHD, DM, etc). If
patient gets convinced and don’t default,
there are lesser chances of relapses and
complication.
Non-verbal Communication (Body
Language) (Fig. 10.2)
This is much more important than verbal
communication. It is involuntary and in most
cases beyond ones control. It is the reflection
of ones inner thoughts and hidden fears of an
individual. Some examples include: nodding
or shaking of the head, frowning, smiling,
touching, hugging, yawning, tears, winking,
averting eyes, crossing arms, etc.
Non-verbal communication can be used in
two ways—both by physicians and patients.
First and most important is to establish
and maintain eye contact with the person to
whom you are speaking. Speaking face-to-face
on the same physical level further enhances
communication. To do this, the physician
often needs to sit in a chair, or perhaps at the
side of the bed, comfortably, yet respectfully.
This tells the patient that the message that is
being communicated is important and will be
relayed in an unhurried fashion.
Facial expressions can speak volumes. Facial
expressions can convey our messages with fairly
Fig. 10.2  Non-verbal skills
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precise accuracy. Our face is very expressive
and can communicate many different emotions
without the use of words at all. Other parts of the
body such as your arms, hands, fingers, etc. can
also be used to communicate. A sympathetic
look or an enthusiastic gesture can convey
support and increase patient’s understanding
of what is being communicated more effectively
than any words.
Conversely, the physician who arrives
several minutes late, takes hurried notes, and
turns away while the patient is talking, almost
always conveys impatience and minimal
interest in the patient, despite any spoken
assurance to the contrary. Thus, it is imperative
that the physicians be aware of their own
image of body language, as well as recognizes
the nonverbal cues of the patient.
Communication with Children
Working with children involves many unique
considerations. When communicating with
children, it is vital to remember that the child is
the patient, but the history is usually recited by
the parent. Therefore, parent is the key person
in any transaction, which may get profoundly
affected (in accuracy and flavor) by the parent’s
observational abilities and interpretations of
the child’s signs and symptoms.
Unless other people are specifically meant
to be included, conversation in privacy is
preferred; the best communication between
the physician and the child occurs when others
are not around.
Looking at a problem from the child’s
vantage point may be quite helpful in both
clarifying the nature of the problem and
planning treatment. Other basic skills and
behaviors which are most helpful when
communicating with children and their
parents are:
™™ To look after the comforts of the child and
the parent, e.g. on the parent’s lap, or the
floor playing with the toys.

™™ To be gentle and led by the child and the
parent’s pace.
™™ To listen carefully and politely, offer
support and praise which will reinforce
and keep communication open.
™™ Not to interrupt the child while telling the
story and to involve the parent as needed.
™™ To use clear language appropriate to the
child’s age.
™™ Not to embarrass, or put the child on the
spot in front of others (e.g. “What do you
know, you’re just a child “); this will lead
only to resentment and hostility, and not
good communication.
Communication with Older Patients15
As the size of the older population increases,
clinical encounters with elderly patients will
become increasingly common in primary
care offices with its growing impact of
non-communicable diseases and chronic
conditions. Because of chronic disease, the
oldest old have the highest population levels
of disability that require long-term care.
Therefore, physicians need to understand
the unique needs of the elderly population so
that they are better prepared to communicate
effectively during visits with older patients.
Older adults* often present with complex
problems and several chief complaints, which
require time to unravel. To some extent, the
skills are the same regardless of the patient
involved. However, communication with
older patients can be made more challenging
as a result of age-related sensory impairment,
such as presbycusis, which particularly affects
high-frequency sounds; visual deficits, such as
cataracts, macular degeneration, glaucoma,
and ocular complications of diabetes; memory
decline and some form of dementia.
*Some gerontologists view the elderly patient population as being composed of several age cohorts: the
young-old (individuals 65–74 years old), the middle-old (individuals 75–84 years old), and the old-old
(individuals 85 years and over).
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Chapter 10: Communication Skills 93
In addition, a third person may be part of
the interaction, as elderly patients often are
accompanied by a family member or loved
one who is actively involved in the patient’s
care and participates in the visit.
Table 10.1 provides general techniques
to enhance communication with older
patients as well as specific strategies to aid
communication with patients who have
sensory or cognitive losses or other caregivers.
T h e u l t i mat e b e n e f i t o f a p p l y i n g
these communication techniques will be
improvement in outcomes for older patients
and their caregivers. With effective physician—
older patient communication, patients are:
™™ More likely to share their symptoms and
concerns, which will enable the physician
to make a more accurate diagnosis;
™™ More likely to follow through with physician
recommendations;
™™ Less likely to skip doses or stop a medication
because of side effects, perceived non-
efficacy, or drug cost; and
™™ More likely to self-manage diabetes with
diet, exercise, blood glucose monitoring,
and foot care.
Barriers in Communication
These may be broadly classified as follows:
™™ D o ctor-patient factors : Po or past
experience like a missed diagnosis; poor
treatment; differences in billing; personal
differences relating to religion, culture,
status, sex, age; familiarity between doctor
and patient such as friends and relatives.
™™ Doctor’s personal factors: Age—too
young/too old; sex—opposite; overly
protective staff; delay in returning a phone
call; overloaded practice; appointment
delays; physical handicaps like speech,
hearing; bias toward patient for reasons
 94  Section 4: The Practice of Family Medicine
Table 10.1  Tips for effective communication with older patients
General strategies
• Gather preliminary data before the appointment, as older patients typically have complex and multiple
health issues.
• Have patients tell their story only once (and not to a nurse or assistant first and then to you) to minimize
patient frustration and fatigue.
• Address the patient by last name, using the title the patient prefers (Mr, Ms, Mrs, etc.).
• Begin the interview with a few friendly questions not directly related to health.
• Avoid hurrying; maintain an unhurried pace, allowing the patient a few minutes to express his/her concerns
if able.
• Use active listening skills; speak slowly, clearly, without shouting, using a calm tone and pleasant expression.
• Do not interrupt at the very beginning (first 20–30 seconds) of the initial interview.
• Respond to patients’ emotions; demonstrate empathy.
• Avoid jargon; try not to assume that patients know medical terminology or a lot about their disease.
• Schedule appointments earlier in the day, as they are generally more alert.
Compensating for Hearing Deficits
• Make sure patient can hear you. Ask about working hearing aid. Examine auditory canal for the presence
of excess earwax.
• Talk slowly and clearly in a normal tone. Shouting or speaking in a raised voice actually distorts language
sounds and can give the impression of anger.
• Be aware that background noises, such as fans and office equipment, can mask what is being said.
• Tell patient when you are changing the subject. Give clues such as pausing briefly, speaking a bit more
loudly, gesturing toward what will be discussed, gently touching the patient, or asking a question.
• Keep a note pad handy so you can write what you are saying. Write out diagnoses and other important terms.
Compensating for Visual Deficits
• Make sure there is adequate lighting, including sufficient light on your face. Try to minimize glare.
• Check that your patient has brought and is wearing eyeglasses, if needed.
• Make sure that handwritten instructions are clear.
• When using printed materials, make sure the type is large enough and the typeface is easy to read. Provide
written instructions in at least 14-point type.
• If your patient has trouble reading, consider alternatives such as providing large pictures or diagrams.
Cognitively impaired patients
• Do not ignore the patient.
• Ask questions simply, using “yes” or “no” questions and simple gestures.
• When performing the examination, give one instruction at a time.
Encounters with third party involvement
• Prepare the environment of the examination room by setting three chairs in a triangle.
• Direct questions initially to the patient, then ask for input from the patient’s companion.
• Ask the patient and the patient’s companion to repeat back any important instructions.
Conclude the visit: Make sure the patient understands:
• What the main health issue is?
• What he/she needs to do about it?
• Why it is important to do it?

of ‘doctor-shopping’; professional incom­ personality disorders like depression,

petence; lack of training; short of time and
running late.
™™ Patient’s personal factors: e.g. false beliefs
such as not to burden the doctor; nothing
can be done; past illness has no relevance
to present suffering; psychological and
anxiety, hysteria, dementia; fears and
phobias of malignancy, HIV; sensitive
issues like sexuality, bereavement.
™™ Others: frustration over telephone system;
billing mistakes; foreign language; altered
mental state.

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Common Communication Pitfalls
Communication may fail to be effective for
several reasons. It is important, therefore, to
recognize the major pitfalls. These include:
™™ Using highly technical language or jargon
when communicating with patients and
family members.
™™ Not pausing sufficiently when delivering
information.
™™ Taking an impersonal approach or displaying
apathy about communicating well.
™™ Not showing appropriate concern for
problems voiced by the patient or family
member.
™™ Not listening to the patient or family
member.
™™ Failing to verify whether the patient or family
member has received and understood
information that has been conveyed.
™™ Not being sufficiently available to the
patient’s family.
Acquiring New Skills
Many new skills are being developed for
helping doctors to acquire relevant communi­
cation skills. They are:
™™ Interactive demonstration—watching
physicians’ interview real patients.
™™ Simulated process—the interviewer asks
a group to suggest strategies to begin the
consultation, elicits views and feelings
about methods used, its impact on patient,
and so on.
™™ Multimedia course—which includes
instr uctional CD-ROM, text-book,
videotape, power point slides.
™™ Internet web site resources: For example:
http://www.healthcarecomm.org/index_
noflash.php? & noflash, and http://www.
hca-uk.org/Careers
Neurolinguistic Programming
A novel concept in communication skills,
called “neurolinguistic programming (NLP)”
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Chapter 10: Communication Skills 95
is being actively advocated to build rapport
with patients. NPL offers mirroring techniques,
both physical and verbal, that can easily be
adapted into the methods in which doctors’
interview patients and take their histories. As
a result, doctors may build better rapport with
their patients, and this is the bedrock on which
effective physician-patient communication is
built.16
Conclusion
Although no single method or medium works
ideal to educate students and physicians on
good communication skills, the best approach
is to teach them these communication
skills from ‘day one’ and refine those skills
throughout medical school. Strengthening
one’s communication skills takes time and
ongoing practice. “This is not something that
one can learn over hours or weeks…it requires
changing ones whole way of thinking”.4
References
1. Williams SL, et al. The therapeutic effects of the
physician-older patient relationship: effective
communication with vulnerable older patients.
Clin Interv Aging. 2007;2(3):453–67. [PMID:
18044195: Free PMC Article].
2. Brann M, et al. E-medicine and health care
consumers: recognizing current problems and
possible resolutions for a safer environment.
Health Care Anal. 2002;10(4):403–15. [PMID:
12814287: Abstract].
3. Akerkar SM et al. Health information on the
internet: patient empowerment or patient
deceit? Indian J Med Sci, 2004;58(8):321–6.
[PMID: 15345885: Abstract].
4. Doug Brunk. Patient Communication Receiving
New Emphasis. Family Practice News, 2001;
31(10):44.
5. Teutsch C. Patient-doctor communication.
Med Clin North Am, 2003;87(5):1115–45.
[PMID: 14621334: Abstract].
6. Dacre J, et al. Communication skills training in
postgraduate medicine: the development of a
 96  Section 4: The Practice of Family Medicine
new course. Postgrad Med J, 2004; 80(950):711–5.
[PMID: 15579610: Free full text].
7. Maguire Peter, et al. Key communication skills and
how to acquire them. BMJ, 2002;325:697–700.
8. Beck RS, et al. Physician-patient communication
in the primary care office: a systematic review. J
Am Board Fam Pract, 2002;15(1):25–38. [PMID:
11841136: Free full text].
9. Booth K, et al. Perceived professional support
and the use of blocking behaviors by hospice
nurses. J Adv Nurs, 1996;24(3):522–7. [PMID:
8876412: Abstract].
10. John Easton. Communication skills diminish
malpractice risk. JAMA, 1997.
11. Virshup BB et al. Strategic risk management:
reducing malpractice claims through more
effective patient-doctor communication. Am J
Med Qual, 1999;14(4):153–9. [PMID: 10452132:
Abstract].
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12. Wilson J. Proactive risk management: effective
communication. Br J Nurs, 1998;7(15):918–9.
[PMID: 9849159: Abstract].
13. Moore PJet al. Medical malpractice: the effect
of doctor-patient relations on medical patient
perceptions and malpractice intentions. West
J Med, 2000;173(4):244–50. [PMID: 11017984:
Free full text].
14. Asrani CH. Art of Communication: bedside
manners-Counselling. Bombay Hosp J, 2000;
42(1).
15. US National Institutes of Health—National
Institute of Aging
Web site - http://www.nia.nih.gov/Health
Information/Publications/ClinicianHB/02_
understanding.htm Accessed on 11-11-2011
16. Huang W. Teaching learners to use mirroring:
rapport lessons from NLP. Fam Med, 2004;36
(8):541–3.
 RAPID ACCESS

11 TO IMPROVING
COMMUNICATION SKILLS

“There is never enough time to do everything, but there is always

enough time to do the most important thing.”
— The Law of Forced Efficiency

Introduction TABLE 11.1  The Calgary-cambridge observation guide

Most family physicians have excellent
communication skills, which has helped to
boost meaningful and trusting relationship
with our family patients over the years. In a
study conducted by Laidlaw Toni Suzuki et al
to assess patients’ satisfaction with their family
physicians’ communication skills, based on
the Calgary-Cambridge Observation Guide
(Table 11.1) , in a random sample of 204 adults
in Nova Scotia (NS) concluded that, “Overall,
the respondents were satisfied both with their
medical care and with their family physicians’
communication skills…. the NS family
physicians seen by our patient sample appear
to have done very well at initiating sessions
by putting their patients at ease and showing
a genuine interest in their patients’ problems.
In terms of gathering information, they also
appear to have been proficient at identifying
the reason or reasons for the consultation by
providing their patients ample opportunity
to discuss all their concerns. Because length
of time with the family physician was not a
significant factor, this suggests that NS family
doctors appear adept at putting both old
and new patients at ease and building good
relationships with them.” 1
The calgary-cambridge observation guide uses
a simple five-point plan to structure individual
communication skills. Based on a sequence of basic
tasks that physicians and patients routinely attempt
to accomplish in everyday clinical practice, the plan
provides a logical organizational schema for both
patient-physician interactions and communication skill
education. As indicated below, each of these five tasks
include an expanded framework of skill sets which
provide further detail about the goals to be achieved.
1. Initiating the session
• Establishing initial rapport
• Identifying the reason(s) for the consultation
2. Gathering information
• Exploration of problems
• Understanding the patient’s perspective
• Providing structure to the consultation
3. Building the relationship
• Developing rapport
• Involving the patient
4. Explanation and planning
• Providing the correct amount and type of
information
• Aiding accurate recall and understanding
• A chieving a shared understanding:
incorporating the patient’s perspective
• Planning: shared decision making
• Options in explanation and planning
– if discussing opinion and significance of
problem
– if negotiating mutual plan of action
– if discussinginvestigations andprocedures
5 Closing the session
Source: Health Canada: Talking Tools II—Putting
Communication Skills to Work—Resource Booklet.

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 98  Section 4: The Practice of Family Medicine
Changing Practice Environment
However, increasing demands on doctors in
today’s healthcare environment often leave
less time to provide care to a greater number
of patients. Besides, in today’s demanding
and cost conscious healthcare system, such
as health maintenance organizations (HMOs),
preferred provider organizations (PPOs)* and
similar “managed care” settings, wherein a
doctor is supposed to see a certain number
of patients per day, many doctors have to cut
down on the time they can spend with their
patients. 2,3 And the first thing that usually
suffers is communication.4,5
The House of Commons Social Services
Committee in 1987 reported that, “shortage
of time in consultation is the major criticism
of general practitioners expressed by patient
organizations, with particular reference to
the failure of doctors to listen. It is clear that
shortage of consultation time is the greatest
obstacle to improvement and extension
of primary healthcare services by general
practitioners”.6,7 On many occasions, not only is
our time with patients cut short, but the loyalty
of our patients some times feels divided with
our needs and demands on one side and the
managed care plan’s cost control efforts on
the other.8,9 As responsible family physicians,
we often find ourselves at the focus of this
concern, trying to balance costs and cures.
Many of us have already been sensing that our
patients, themselves are different today. The
family we once cared for from birth to death
has now switched to a HMO you don’t contract
with, and many of our new patients act more
like “consumers”, looking for the best bargain
than as “partners” in trusted physician –patient
relationship.10
Given this changing practice environment,
it is important that we in our role as patient
advocates find ways to see more patients in less
time and still be an effective communicator.
While time constraints can make it difficult to
communicate as effectively as one would like,
the quality of time spent with the patient remains
very important. These circumstances, therefore,
provide a unique challenge to the physician to
deliver excellent medical care while complying
with the guidelines of the organization within
which he or she practices. For this reason,
effective patient-focused communication skills
are essential. They can be applied quickly and
effectively within the normal patient encounter.
Refining Communication Skills
To achieve this objective, “we need to
communicate smarter by making better
use of the time we have got, refine our basic
communication skills, and make essential
adjustments in our communication style to
accommodate today’s more participatory style
of care, and take steps to go that extra mile.” 11
While one of the main reasons cited
by clinicians for poor communication and
relationship building with patients is a lack of
time, there is evidence that longer visits do not
necessarily improve communication.12-14 As
the internationally acknowledged economist
Andrew Barnett states, “More communication
can simply end up as a form of pushing
knowledge down a hose-pipe, in the hope that
at least some of it will come out the other end.”15
In this context Mauksch LB et al,16 have created

*HMOs are is a type of managed care organizations that provide a form of health care coverage in the
United States that is fulfilled through hospitals, doctors, and other providers such as pharmacies, labs,
X-ray centers, and medical equipment vendors, with which the HMOs have a contract. Most HMOs require
members to select a primary care physician (PCP), a doctor who acts as a “gatekeeper” to direct access to
medical services. A PPO is a health plan that has contracts with a network of “preferred” providers from
which a person can choose. There is no need to select a PCP and the person does not need referrals to see
other providers in the network.

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 Chapter 11: Rapid Access to Improving Communication Skills 99
a comprehensive communications model,
directed at primary care providers, that blends
the quality-enhancing and time-management
features of selected communication and
relationship skills with an aim to improve
communication and overcome possible
obstacles that occur in a doctor’s office:
Greeting the Patient: Rapport Building
The first impression a doctor and a patient
make of one another is the most important
one. In those first few minutes in the room with
the doctor, the patient will decide if he/she can
feel comfortable sharing information with the
doctor. This is an indication of the doctor’s role
and a starting point for rapport building.
A smile, a warm greeting with a hand shake,
addressing the patient by name (first name
or surname whichever the patient prefers),
and an inquiry on an important life event can
build rapport in less than a minute. Both the
doctor and the patient must sit down at eye
level; this relaxes the patient, so that both can
communicate more openly.
Do Not Appear Rushed, Even if You are
Patients are greatly irritated when their doctors
appear hurried. Non-verbal behaviors such as
looking at your watch and keeping one hand on
the doorknob could make the patient feel that
they’re being rushed. These behaviors imply
that the patient in the room isn’t as important
as the one who’s coming in next. Once you’re
in the examination room, make sure you’re
really there; focus your attention on the patient
and stop yourself from being preoccupied
with what’s happening on the other side of the
examination room door. Establish procedures
in the office minimizing interruptions unless
absolutely necessary.
Keep Conversation on Track
Determine the patient’s priorities (e.g. “What
would you like to talk about today?” “Tell me
what’s troubling you most.”).
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Helping patients stay on track will increase
efficiency and maximize the value of the time
you have with them. While most patients
present their complaints in a straightforward
way, others tend to deviate. While one can gain
some useful information from their departures,
the doctor has to use his experience to
determine when the conversation begins to
lack relevance and gently guide it back to the
matter at hand.
Listen without Interrupting
Allow the patient to speak without interruption.
Active listening requires attention, patience
and suppression of the urge to control the
conversation. By actively listening to the
patient without interruption the doctor will
get more information which will save time in
the long run. Communication is more effective
if the listener focuses only on what is being
said. Studies have shown that if the doctor lets
patients speak for the first 3–4 minutes, they
tell us 90% of what’s wrong with them.
Relate with Your Eyes
Avoid focusing on a computer screen, writing
notes or reading case sheet; look into the
patient’s eyes. Your contact should be direct
but intermittent (not staring) and it should be
sincere and convey interest. Maintaining eye
contact and sitting when talking to patients can
communicate attention and respect.
Organize Your Interviews
Most family physicians excel at interviewing—
avoiding statements that might evoke
defensive responses. In an effort to be
comprehensive, however, some interviews
may go on too long, especially those related
to complex psychosocial causes such as
anxiety, depression, and situational stress
disorders. Under such circumstances, it is
worth trying the “BATHE” technique.17 The
 100  Section 4: The Practice of Family Medicine
BATHE technique* consists of five specific
questions about the patient’s background,
affect, troubles, and handling of the current
situation, followed by an empathic response.
Background: Tell me what has been happening;
what is going on in your life?
Affect: How do you feel about that. It allows the
patient to reflect on their feelings and to know
that their emotions are being recognized.
Trouble: What’s upsetting you most about it?
This is a key question, as it helps the patient
and doctor focus on one thing, the most
important problem. The most time-consuming
patients present with five or six problems, so
this can be a huge time saver.
Handling: How are you handling the situation?
This includes a presupposition that the patient
is handling it at some level, however badly,
and ensures that the problem belongs to the
patient and is not for us, the GP, to take on, so
protecting us from transference.
Empathy: Empathy demonstrates under­
standing and normalizes the situation. Use
phrases such as ‘That must be very difficult
for you.’
Practice Participatory Care
Involve the patient in their care and treatment,
making them partners in their health or
recovery. Where appropriate, it may be
necessary to include the patient’s close
associates in the partnering philosophy of
health education and information where
feasible. In a study contrasting different style of
patient care it was found that physicians who
used a “participatory” model of care (i.e. the
doctor serves as an educator, shares decision
making and encourages patients to participate
*BATHE technique: The procedure takes approximately 1 minute and must be practiced. Physicians may
use it to connect meaningfully with patients, screen for mental health problems, and empower patients
to handle many aspects of their life in a more constructive way.
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in their care) had twice the patient retention
rate as physicians using the traditional
“authoritative” style of cure.18
To move toward this “participatory”
style of cure, physicians need to encourage
patient’s interaction, keep conversation at the
patient’s level of understanding, and let the
patient do most of the talking. Patients who
take partnership role in their care will often
share more information with their doctors
and may be more motivated to comply with
the treatment plan.
Set Realistic Expectations—Provide
More Information in Less Time
Media coverage about medical advances
and new technologies has created unrealistic
expectation that doctors can diagnose and
cure just about anything. The media hype
and its tendency toward “publication bias”,
i.e. greater likelihood for favorable studies
than for negative studies to get published,
may actually harm the patient. Since most
patients do not understand the practice of
medicine and have little understanding of
the complexities involved in their treatment,
it’s for the doctor to explain to the patients
what is realistic by explaining the facts which
is time consuming. One way to deal with
such “information overload” in a time saving
manner is to integrate patient education
materials into the office visit. It is advisable
to maintain a file of education handouts
and brochures that are freely available from
medical websites and distribute to patients
as per their disease requirements. This can
be done by any qualified staff member in the
office, or who can provide patient education
on medication, drug-interaction and explain
disease management. The doctor at a later
 Chapter 11: Rapid Access to Improving Communication Skills 101
convenient appointment can explain any
discussion on other important matters. In
some practices patients can help themselves
to a patient education library, stocked with
brochures, books, videotapes, etc. that are
conveniently housed separately.
Going that Extra Mile
Even after you have refined and adjusted
your style of practice there is still more you
can do to meet and exceed your patients’
expectations. To make your patients even better
informed while enhancing the doctor-patient
relationship, consider doing the following.
Give All Patients a Welcome Letter/
Biography
A welcome letter providing an insight into
the kind of care your patient can expect to
receive will make the patient feel familiar with
you and your practice at the first office visit.
(Ref. A sample welcome letter). You may also
include a brief biography of yourself and your
colleagues practicing with you (Ref. Sample
Biography).9, 19
Another tool you can use with a new
patients is a hand out of a short medical
questionnaire 20 which provides a quick
medical history and can “jump start” the first
examination. The questionnaire, besides,
economizing time, helps you with valuable
background information on the patient. It
also sends a message that you are interested
in the patient’s total wellness. The health
questionnaire should cover standard questions
regarding medical history; it should include
emotional aspects of the patient and other
issues important to your practice.
Use Internet/Computers Creatively
Electronic Medical Records: Work toward the goal
of establishing a fully EMR system. Establish a
secure database for all patients’ demographics,
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diagnosis, allergies, medications, etc. in digital
form for ready access.
E-mail: Many physicians are now using e-mail
to answer patients’ questions. One can even
have fixed e-mail hours, which saves time
besides being faster and more convenient to
both the doctor and his patients.
Web site: Develop an interactive web site for
your practice, using a secure communication
mechanism to meet various practice
protocols, such as mediclaim requirements,
appointments, remainders, details of practice
procedures, etc.
Education: The doctor can also inform patients
about Internet sites, and web addresses that
are specific to their health care needs.
Update and customize office information
technology. Hand held computers, telemedicine/
teleconferences and many such advances are
only a click away both to the doctors and patients.
Educate Your Staff
Communication isn’t just a doctor-patient
issue. Your office staff also represents you to
your patients. In order to maintain over all
efficient and cordial relationship between
your staff and patients, it is important that they
have periodic staff training sessions on patient
communication and related topics. They will brief
your patients with pertinent information before
their examination which will save your time.
Follow-up
The doctor has to make sure that all questions,
concerns and patient related needs have
been fully addressed and discuss with the
patient the next steps in care, set up follow-up
monitoring (if needed) or at least reinsure the
patient to feel free to come back to see him/
her again.
When patients do not attend follow-ups,
it is better to call for information, rather than
just leaving it for the patients or the referral
 102  Section 4: The Practice of Family Medicine

A SAMPLE OF WELCOME LETTER

Name:.................................

Address:..............................

E-Mail:................................. TEL:.................................

Mobile No.:.......................... Fax:.................................

Office Hours:....................... Emergency contact Tel. No.:

Dear Mr/Mrs.....................................................................

Welcome to my practice. I am honored to be your physician and I am committed to provide you with the best
care I can and help you always to lead a healthy life style.
Here are some important steps you can take toward better health:
• Don’t smoke cigarettes.
• Don’t use tobacco products.
• Exercise at least thrice a week.
• Eat a diet low in fat and high in vegetables and fruits.
• Wear your seat belt whenever you are in a car.
• Drink alcohol in moderation, if at all.
• Learn to manage stress and tension.
• Don’t mix alcohol and driving.
• Discover what spirituality means to you and practice it.
• Maintain ties with your family, friends, neighbors, co-workers and others in the community.
It gives me great pleasure to work with you on these goals, either through my own expertise, through reading
the self-help books I give you, or by referral to other health professionals.
A good beginning would be to have a complete physical examination. No matter what your current state of
health—followed by periodic check-ups to test for a few specific diseases. I look forward to working with you
as your family doctor. The lines of communication are always open. Let’s work together to lead a healthy,
satisfying life that you deserve.

Sincerely,

……………………….

SAMPLE OF BIOGRAPHY
Our Physicians
1. Dr A is a qualified family physician with an experience of about ……… years. He has an added qualification
in ……… medicine. He is a straightforward individual who leads by example. He is a member of .……
faculty/organization.

2. Dr B is board certified in family practice with an experience of about ……years. She has an added
qualification in Medicine. She is a working mother with two children and offers patients the warmth and
grace that only a mother can provide.

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 Chapter 11: Rapid Access to Improving Communication Skills 103
physician. This will help the doctor to maintain
continuity of their care as well as showing them
that the concerned doctor is interested in their
health matters. Of course, it is important to be
sure that patients understands that keeping in
touch is a two-way affair and that they you are
expected to do their share of co-operation.
Conclusion
Many physicians find themselves in an
environment where they must deal with a
patient within a restricted time frame, and
under “managed care” guidelines that may
at times compromise their ability to exercise
their optimal clinical judgment. With shorter
patient visits now a reality, physicians have
even less time to “make or break” the patient-
physician relationship. However difficult
these restrictions may be, it is the ultimate
responsibility of the physician to determine
what is best for the patient; this responsibility
cannot be relinquished in the name of
compliance with managed care guidelines.21
It is therefore, vital that physicians develop an
understanding of their own communication
style and adjust that style to meet the needs
of various patients, which will result in more
work satisfaction and increased productivity.
References
1. Laidlaw Toni Suzuki, et al. Patients’ Satisfaction
with Their Family Physicians ‘Communication
Skills: A Nova Scotia Survey. Academic
Medicine: 2001;76(10):S77–S79.
2. Mechanic D, et al. Are patients’ office visits
with physicians getting shorter? N Engl J Med,
2001;344(3):198–204. [PMID: 11172143: Free
Article].
3. Blumenthal D, et al. The duration of ambulatory
visits to physicians. J Fam Pract, 1999;
48(4):264–71. [PMID: 10229250: Abstract].
4. Hull FM, et al. Time and the general
practitioner: the patient’s view. J R Coll Gen
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Pract, 1984; 34(259):71–5. [PMID: 6471020:
Free full text].
5. Ogden J, et al. “I want more time with my
doctor”: a quantitative study of time and the
consultation. Fam Pract, 2004;21(5):479–83.
[PMID: 15367468: Free Article].
6. Wilson A. Consultation length in general
p r a c t i c e : a re v i e w . B r J G e n P r a c t ,
1991;41(344):119–22. Review.[PMID:2031756:
Free PMC Article].
7. House of Commons Social Services Committee.
First report, session 1986-87. Primary health
care. London: HMSO, 1987.
8. Leibowitz R, et al. A systematic review of
the effect of different models of after-hours
primary medical care services on clinical
outcome, medical workload, and patient and
GP satisfaction. Fam Pract, 2003;20(3):311–7.
[PMID: 12738701: Free Article].
9. Born PH, et al. Health maintenance organization
(HMO) performance and consumer
complaints: an empirical study of frustrating
HMO activities. Hosp Top. 2004;82(1):2–9.
[PMID:15490955:Abstract].
10. Teutsch C. Patient-doctor communication.
Med Clin North Am, 2003;87(5):1115–45.
[PMID: 1462133: Abstract].
11. Belzer Ellan. Improving communication skills
in no time. Fam Pract Management, 1999;
6(5):23–28.
12. Cape J. Consultation length, patient-estimated
consultation length, and satisfaction with the
consultation.Br J Gen Pract, 2002; 52(485):1004–
6. [PMID: 12528588: Free full text].
13. Wilson AD, et al. Effects of interventions
aimed at changing the length of primary
care physicians’ consultation.Cochrane
Database Syst Rev, 2006;(1):CD003540. [PMID:
16437458:Abstract].
14. Carr-Hill R, et al. Do minutes count? Consult­
ation lengths in general practice. J Health Serv
Res Policy, 1998;3(4):207–13. [PMID: 10187199:
Abstract].
15. Barnett, Andrew. Reducing poverty needs an
‘innovation system’ approach’, SciDev.Net, Web
site - www.scidev.net/dossiers/index.
 12 The consultation

“The most important difference between a good and an indifferent clinician

lies in the amount of attention paid to the story of a patient.”

Introduction Impression is created, guidelines are worked

out, and critical data are collected. Because
C o n s u l t at i o n may b e d e f i n e d a s a n
this is usually the first meeting of the two
interpersonal process, between the patient
individuals involved, the conduct and the
and the physician, evaluating aspects of health
progress of the consultation are as important
care, involving both verbal and nonverbal
as the content of the history.
events that may facilitate the understanding
Preparation for a successful consultation
of patient’s illness.
begins with the doctor assuming a professional
The consultation is the cornerstone
role. Formal introduction, exchange of
of all that we do in family practice. It has
greetings, a quiet environment, comfortable
been usefully employed to assess doctor’s
sitting arrangements, and privacy are some
effectiveness in terms of achieving the clinical
of the important conducive aspects to a
diagnosis. Most information leading to
successful consultation.
solution of any individual patient’s diagnostic
There are many consulting models* to
mystery is gathered from medical history taken
help doctors to understand the consultation;
during the consultation. Evidence shows that
most of them are similar in their attempt to
in over 75%, the history obtained by clinicians
broaden the conventional medical approach
at the consultation led to the diagnosis. Most
to include psychosocial issues, the family, and
clinicians rate the patient’s medical history as
the physician (Table 12.1).3,4
having greater diagnostic value than either the
physical examination or results of laboratory
investigations. The clinical adage that about Objectives for the Consultation
two-thirds of diagnoses can be made on the These are mainly 2-fold—patient’s and
basis of the history alone has retained its doctor’s consultation objectives:
validity despite the technological advances of
the modern hospital.1,2 Patient’s Objectives
During consultation the doctor and the Helman’s ‘Folk’ Model 5 helps understand
patient establish their working relationship. why patients come to the doctor. He states
*Consultation models are simplified procedures that give a framework for learning and teaching the
consultation, and to create an increased awareness of how consultations work in general practice. This is
helpful in identifying the skills that are needed to achieve the desired outcome. They actually soon become
second nature of general practitioners in practice.

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that when a patient becomes ill he desires to
seek answers to six questions. These questions
may not be explicit; however, they need to be
incorporated with in a consultation for it to be
fully effective.
™™ Identity: What has happened? What is it?
™™ Cause: Why has it happened? What caused
it?
™™ Self-appraisal: Why to me? Why now?
™™ Timeline: How long will it last?
™™ Consequences: What would happen if
nothing were done? How will it/has
affected me?
™™ Cure/control: Can it be cured or controlled?
What should I do about it, or whom should
I consult for further help?
Doctor’s Objectives
™™ To maintain the doctor/patient relationship.
™™ To help the patient to present problems.
™™ To educate and involve patients in their
own care.
™™ To satisfy the patient if possible and
appropriate.
™™ To consider long-term management.
™™ To promote compliance.
™™ To use time and resources appropriately.
Tasks in the Consultation6
The doctor performs many tasks in the course
of the consultation. These can be grouped as:
Principle Tasks
™™ Relieve illness: Patients consult doctors to
seek relief from the illness and suffering,
and if possible, a cure or healing. This is the
primary task in the patient-doctor encounter.
™™ Relieve suffering: The second task is to
relieve suffering. There is much that could
still be done even if it is not possible to
cure the patient’s illness, e.g. chronic
medical conditions like diabetes mellitus,
hypertension, bronchial asthma and end-
of-life illness.
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Chapter 12: The Consultation 105
™™ Reassurance: The third and perhaps equally
important task is to provide reassurance to
the patients that they are in good hands
and that family doctors are doing their best
in the circumstances.
Ambrose Pare, a 15th century French
surgeon, sums up these three tasks aptly: “To
cure sometimes, to relieve often, but to comfort
always”.
Understanding Tasks
The three principle tasks need for their
expression, two understanding tasks:
™™ The task of understanding patients’ “ideas,
concerns, and expectations” (i.e. ICE- see
below) for care, and
™™ The task of understanding their clinical
problems.
From the accomplishment of these tasks,
follow the processes of management of both
patients’ and their illness.
Management Tasks
On understanding the patients’ and their clinical
problems, comes a series of potential patient
management tasks for the doctor to perform;
which depend to a large measure on time
available, knowledge, skills, and awareness.
™™ Management of presenting problems:
Every consultation needs to address this
area. Besides, dealing with the presenting
problems, it is a good practice to embark
on the other tasks (explained below) as far
as time permits.
™™ Modification of help-seeking behavior:
Occasionally, it may be necessary to change
the help-seeking behavior. For example,
the patient may insist on antibiotics, which
are not appropriate. The modification
of such behavior needs due attention to
ideas, concerns and expectations behind
the help-seeking behavior.
™™ Management of chronic problems :
These need to be addressed whenever
 106  Section 4: The Practice of Family Medicine
patients’ visit. Time spent in this task will
result in better compliance and reduce
complications from chronic diseases.
Opportunistic health promotion*—A
consultation in primary health care is ideal
for opportunistic health promotion and
disease prevention. Much can be done
to reduce the onset of disease related to
adverse life-style such as sedentary habits,
tobacco and alcohol abuse. However, this
is a challenging task because the adoption
of healthy behaviors requires change of
life-long habits.
The Consultation Process
The consultation process is aimed at fulfilling
two tasks: understanding patients and their
clinical problems. Two methods are commonly
used in clinical practice:7
Doctor-centered Method
The conventional method pays attention to
present complaints, analysis of symptoms and
physical findings, diagnosis, investigations and
then treatment. This method fits the “hospital”
setting where the focus is on doctor dominated
biomedical problems with reductionist
approach.** Understanding the patient and what
the illness means to the patient usually tends to
be an afterthought, something added on after the
diagnostic task has been completed.
Patient-centered Method
The patient-centered method represents
a reformed clinical method to suit the
“ambulatory” care consultation, wherein
patients bring to their doctors problems that
may not be entirely biomedical.  Although
patients attend with a set of symptoms, they
also have “ideas, concerns, and expectations”
*Ref. Chapter 34 Prevention in Family Practice: opportunity for prevention.- p. no. 338
**Ref. Chapter 8 The spectrum of clinical diagnosis. - p. no. 63
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(i.e. ICE as defined in Pendlenton et al).
Patients dwell on such real issues confronting
them; this is often described as the “patient’s
agenda”. Doctors, based on their expertise and
experience, decide on an appropriate agenda
(e.g. what are the important needs to be
discussed, in what order, and time-allocation)
after acquiring sufficient information,
including assessing their ICE. This approach
results in doctors having better understanding
of not only the patients, but also their illness.
Although no disease-specific (i.e. bio-
medical) diagnosis is possible in 25–50% of
patients, the patient-centered method can be
used to elicit fuller history than doctor-centered
approach, while also addressing the patient’s
understanding and worries regarding their
symptoms. Even when a biomedical diagnosis
can be made, successful management often
requires an understanding of the psychosocial
issues concerned to the disease.
The patient-centered approach has gone a
long way and the concept of “Patient-Centered
Home Care” (PCMH) has emerged as a new
polestar.8,9 The PCMH is a team-based model
of care led by a personal physician who
provides continuous and coordinated care
throughout a patient’s lifetime to maximize
health outcomes. The PCMH practice is
responsible for providing for all of a patient’s
health care needs or appropriately arranging
care with other qualified professionals. This
includes the provision of preventive services,
treatment of acute and chronic illness, and
assistance with end-of-life issues. It is a
model of practice in which a team of health
professionals, coordinated by a personal
physician, works collaboratively to provide
high levels of care, access and communication,
care coordination and integration, and care
quality and safety.10-12

Table 12.1  Consulting models in general practice
• Eric Berne’s (1964)
• John Heron (1975)
• Bryne and Long (1976)
• Stott and Davis (1979)
• Helman’s “ Folk” model (1981)
• The Disease—Illness model (McWhinney1984)
• Balint (1986)
• Neighbor (1987) 
• Cohen-Cole and Bird (1989)
• Stewart et al (1995)
• T h e C a l g a r y - C a m b r i d g e A p p r o a c h t o
Communication Skills Teaching (1996)
• BARD 2002 Ed Warren (2002)
• Pendleton, Schofield, Tate and Havelock (1984,
2003)
• Traditional medical model: the classical medical
diagnostic process involving history, examination,
investigations, and definitive diagnosis.
Several older models of such approach are
available in the literature (Table 12.1); three
of these are summarized below to give some
background to how the more recent models
have developed.
Pendleton, Schofield, Tate and
Havelock Model13
This model details seven tasks as follows:
™™ To define the reason for the patient’s
attendance, including the nature and
history of the problems, their etiology;
patient’s ideas, concerns and expectations
(i.e. ICE), and the effects of the problems
on the patient,
™™ To consider other problems: e.g. continuing
problems and risk factors,
™™ To choose with the patient an appropriate
action for each problem,
™™ To achieve a shared understanding of the
problems with the patient,
™™ To involve patients in the management
and encourage them to accept appropriate
responsibility,
™™ To use time and resources appropriately: in
the consultation and in the long term, and   with the patient, especially when language and
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Chapter 12: The Consultation 107
™™ To establish or maintain a relationship
with the patient that helps to achieve other
tasks.
Stewart et al Model
The method has six integrated components:
™™ Exploring and interpreting both the disease
and the illness experience,
™™ Understanding the whole person,
™™ Finding common ground with the patient
about the problem and its management,
™™ Incorporating prevention and health
promotion,
™™ Enhancing the doctor-patient relationship,
and
™™ Being realistic about time and resources.
Byrne and Long Model
It involves the following steps:
™™ The doctor establishes a relationship with
the patient,
™™ The doctor, either attempts to discover,
or actually discovers the reason for the
patient’s attendance,
™™ The doctor conducts a verbal or physical
examination, or both,
™™ The doctor, or the doctor and the patient,
or the patient (in that order of probability)
considers the condition,
™™ The doctor, and occasionally the patient,
details further treatment or investigation, and
™™ The consultation is terminated, usually by
the doctor.
It is evident that the three models have
much in common and essentially require
the attending doctor to pay attention to the
following four aspects:
Why does the Patient Come?
The doctor needs to know why the patient
has come for medical help and what help
the patient is seeking. Too often wrong
assumptions may be made by not clarifying
 108  Section 4: The Practice of Family Medicine
cultural barriers exist. Cultural assumptions*
and expectations shape the doctor-patient
relationship and may present a formidable
barrier to effective care.14
It may be assumed that the patient has
come to the doctor because of the symptoms;
but for every patient who presents there
are many more who are coping with similar
symptoms themselves and not seeking help.
Therefore, it is not sufficient to know what
symptoms the patients are experiencing, but
also what sense the patients have made of
their symptoms in order to know why they
have come. Some simple questions can help
to uncover the link to patient’s symptoms:
™™ Can you describe in detail the events that
led to the present symptoms?
™™ What triggers the symptoms?
™™ What makes it worse or better?
™™ How often does it occur?
™™ Do symptoms occur at a particular time
or any event?
™™ Can you predict when it will next occur?
Further, the physician’s conclusion derived
from the following questions to the patient can
facilitate sympton analysis:
™™ Do the patient’s reported symptoms make
sense in the context of all test results and
assessments?
™™ Is there any collateral information from
other sources that confirm the patient’s
information?
It is often assumed that the patients come
for treatment, but what they may need is an
assurance that something more serious is not
going on because they have seen someone with
a serious problem having similar symptoms;
their concern is that they may have the same
problem (see “hidden agenda” below). For
example, patients with somatoform disorders
such as hypochondriasis, characterized
*Cultural competence has been defined as “the ability of health care providers and institutions to deliver
effective services to racially, ethnically, and culturally diverse patient populations.” (Ref. Bigby J, ed. Cross-
Cultural Medicine. Philadelphia, PA: American College of Physicians; 2003).
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primarily by physical symptoms for which
no demonstrable organic explanations or
physical findings exist. The fear or idea is
based on the misinterpretation of bodily signs
and sensations as evidence of disease. The
illness persists despite appropriate medical
evaluations and reassurance.
Family physicians also encounter patients
whose symptoms switch from organ to organ
(hence the name “organ recital”), and some
patients stay within one organ system but their
symptoms keep alternating with each visit. Its–
“as soon as one thing is fixed, something else
goes wrong.” Repeated physical examinations/
lab tests are non-contributory; in fact the false
positive and/or negative reports add further
dilemma to the diagnosis. Such patients are
known by different terms; some call them
“heart sink patients”. Many of these patients
have a “thick file” in the doctor’s office, and
informally called as “thick-file or fat-folder
patients”.
Understanding the Whole Person
Beliefs, customs, and cultural diversity all
play a role in how a person reacts to an
illness, copes with changes, and adapts to
the healing process. The person has “ideas,
concerns, and expectations” (i.e. ICE), and also
other problems that may need attention, e.g.
continuing problems and risk factors, including
limitation of time and resources.   Evidence
proves that the application of a whole-person
model for diseases, especially of chronic
nature, has brought improved engagement
with the individual and more efficient delivery
of health care outcomes. 15 Therefore, by
knowing the patient’s “ICEs”, the doctor is in
a better position to bring about outcomes the
patient desires.

Find Common Ground for Action
At the conclusion of the consultation the
doctor should summarize patient’s concerns as
far as possible and explain matters sufficiently
and clearly, so that the patient understands
and remembers all what has been said and be
committed to the management plan.
Manage the Patient’s Disease Realistically
The goal should be for patients to follow the
planned management when appropriate and
ultimately experience beneficial changes in
their health.
The doctor should emphasize compliance*
with therapy. A patient who is unable or
unwilling to follow the advice given will
frustrate the most careful diagnosis and
appropriate management. Some reasons for
non-compliance are:
™™ The advice may not fit in with the patient’s
lifestyle.
™™ The advice may be too complicated for the
patient to follow.
™™ The advice is related to a diagnosis that the
patient is trying hard to reject.
™™ Inability of the physicians to explain timing
and dose or benefit of medication.
™™ Other reasons, e.g. lack of time or other
resources.
In the experts’ view, a positive attitude
toward treatment, insight into illness, accurate
perception of the symptoms, and the doctor-
patient relationship correlate strongly with
compliance.16 Therefore, the most significant
point to note is that, advice will be rejected
when it does not fit in with the patient’s own
view of the problem. Doctors rarely explain to
the patients the reasons why the advice has
been given, which results in the patients often
*Compliance may be defined as the degree of fidelity to treatment recommendations and patient
cooperation.
**Treat patients as you would like to be treated yourself.
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Chapter 12: The Consultation 109
having difficulty in trying to work out what may
have led the doctors to their conclusions.
Interviewing Skills
This is the most important phase of the
consultation that elicits information verbally
from the patient that is unsurpassed in
diagnostic efficacy. Obtaining accurate and
sensitive information, called as “history of
presenting complaints”, need not be time-
consuming task if the right approach is
followed. A common mistake is to rush into
investigations before considering the history
or examination. It needs to be emphasized that
the art of consultation is to devote all the time
and attention to the patient and nothing else;
time invested to establish trust and rapport
initially will be more time-efficient in future
consultations.
It is convenient to divide the interview in
a consultation into three phases:  beginning,
main part, and ending. However, physicians
with experience usually develop their own
style that they feel comfortable with.
The Beginning**
™™ Greet the patient; introduce yourself,
especially to new patients; the patient must
know who you are.
™™ Put the patient at ease; consider physical
comfort. The atmosphere of the consultation
should be calm, gentle, and respectful.
™™ Obtain some background information
about the patient, e.g. name, how they
would like to be addressed (personal name,
surname), age, status, occupation, etc.
™™ It may be prudent to assure the patient that
you will treat all the information in strictest
confidence.
 110  Section 4: The Practice of Family Medicine
™™ Remember that the patient is evaluating
the doctor, as the doctor is evaluating the
patient. Both may tell each other what they
want to discuss, and what they prefer not
to discuss.
The Main Part of the Interview
™™ Listen to the patient. It is important to allow
the patient to talk. Make eye contact, and
encourage talking by:
ƒƒ Using open ended questions.  vague, or keep changing their story, or talks
ƒƒ Facilitating responses by saying “yes”,
“I understand”,” go on.”
ƒƒ Showing your interest in what the
patient is saying.
ƒƒ Leave direct questioning to the end.
™™ Encourage the patient to be relevant.
™™ Help patient describe the real nature and
development of any problems.
™™ Review the patient’s history with them; it
allows correction of any misunderstanding,
and allows to bring the patient back to the
point that you may wish to explore in
greater detail.
™™ Look out for important leads, verbal and
non-verbal, and follow them up. This is
particularly important when exploring
patient’s understanding of their problems
and its impact on their life (see below).
™™ Use language which the patient will
understand.
Details of Techniques Used in Main Part
of Interview
™™ Use appropriate open ended questions
to help patient outline key problems; e.g.
“What has brought you to see me today?”;
“What seems to be the problem?”; “How
can I help you?” Skill at asking such
questions probably determines one’s
success as a physician more than any other
factor.
™™ Encourage patients to tell their story in
their own words by:
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ƒƒ Facilitation—Verbal, e.g. “Go on, tell
me more about it”, “What happened
then?”, “You said you felt a pain”, etc;
or non-verbally, e.g. head nodding,
looking, attentive posture.
ƒƒ Listening—giving the patient sufficient
time to talk and avoiding coming in too
quickly with questions or reassurance.
™™ Encourage patients to be relevant by
bringing them back to the point if they are
about unhelpful areas of experience, e.g.
by saying, “That’s interesting, but could
we return to talking about your headache.”
™™ Help patients to describe the real nature
and development of any problems by:
ƒƒ Encouraging them to provide actual
examples of the problems and their
effects, e.g. “You say you are having
panic attacks—can you describe a
typical one?”
ƒƒ Paying attention to verbal leads (I have
had this terrible pain; I have not been
sleeping very well, I have been so
miserable) and non-verbal leads
(patient looks in agony; looks upset).
ƒƒ Avoid the use of jargon—by the
patient, e.g. “What do you mean by
‘depression’?”; or by the interviewer,
e.g. “Were you depressed?”
ƒƒ Avoid biasing patient’s story by leading
questions such as, “You are depressed?”,
and “You couldn’t breathe very well”?
Instead use open-ended questions,
e.g. “how was your mood at that time”,
“How was your breathing?”
ƒƒ Avoid multiple questions such as,
“Were you losing weight, appetite,
sleep?” Instead ask single questions,
e.g., “What about your weight?”
™™ Avoid confusion in the history you obtain
by:
ƒƒ Asking the patient to be precise about
dates of onset of key symptoms,

problems or events, nature of previous
treatments, etc.
ƒƒ Clarifying any uncertainties that arise
in the interview, e.g. “I’m not very clear
when your trouble started, could we try
and get that clear?” It may be essential
to state the same question in several
different ways at different points of the
interview (in order to be sure you have
consistent answer) may be helpful.
ƒƒ Crosschecking key points, e.g., “You
said it all began after the demise of your
husband, and not earlier…?”; “You are
breathless only when you walk uphill….?”
™™ Picking up and checking out cues.
In the course of consultation patients very
often provide cues, i.e. a hint or intimation
that provide vital lead to explore some
unexplained aspects of patient’s illness. 17
Usually this happens when it is difficult for
patients to disclose personal information
about themselves or problems they may be
experiencing. A study by Tuckett et al 18 shows
that patients are keen to disclose their own
thoughts and feelings, and offer an explanation
of their symptoms to the doctor; however,
only 7% of doctors actively encouraged
their patients to elaborate, 13% listened
passively, and 80% made no attempt to listen
or deliberately interrupted. Half of patient’s
views were expressed covertly rather than
overtly, with overt cues being picked up far
more readily than covert cues. The conclusion
here is that many patients provide cues which
doctors unfortunately ignore.
Cues can be verbal, non-verbal, or both*.
Studies show that open-ended questioning,
attentive listening, and careful observation
are essential to ensure accurate interpretation
of cues. The physician has to establish an
atmosphere of interest and openness to
explore patient’s feelings and thoughts to
surface during the attentive stage of listening
at consultation and explore these cues further
*Ref. Chapter 10. Communication skills- Communication types; p. 91, 92.
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Chapter 12: The Consultation 111
B. Bub in his article. The patient’s lament 19
expresses these cues as, “Notice handshake,
eye contact, facial expression, body posture,
speech pattern, and choice of language. The
theme of the lamenting person’s narrative
is often peppered with disempowering
words such as buts, cant’s, shoulds, musts,
and if onlys. Notice also: hopelessness,
pessimism, weariness, loneliness, and
negativity.” Therefore, when the patient does
reveal sensitive information, take a moment
to explore what they have told you. It is
appropriate to point out discrepancies to the
patient and elicit their understanding about
their cause. The Table 12.2 gives common
guidelines to explore cues.
Ending the Interview — Hidden Agenda
Patients often tell very important things to
family physicians as they are just about to
leave the office which they could not voice
until adequate courage was summoned at the
moment of departure. Such unvoiced concerns
are generally called as patient’s “hidden agenda”
and known variously as “hand-on-the-doorknob
syndrome”20, or “exit problem”, or “parting shot”,
or “by-the-way shots.” Some reasons attributed
for patients’ hidden agenda are:
Table 12.2  Examples of cues during consultation
Verbal cues
• “You seem quite nervous. Can you tell me why
you might be a bit anxious?”
• “You mentioned you feel overwhelmed. Can you
tell me more about that?”
• “You mentioned you have problems since your
mother died. May I know more about these
problems?
• “What do you mean when you say you always
feel tired?”
• “You mentioned your brother has rheumatoid
arthritis. Is this bothering you now?”
Non-verbal cues
• “I can see you are upset; e.g. your hands are
shaking; voice is chocked; tears in eyes; crying;
unusual sweating; tense facial expression;
anger; sadness; etc.
 112  Section 4: The Practice of Family Medicine
™™ Patient embarrassed to talk about problem
(e.g. sexual problem, depression).
™™ Patient not sure of trusting particular doctor.
™™ Patient worried if confidentiality will be
maintained.
™™ Patient not sure if problem is legitimate
problem to present to the physician
(e.g. bereavement, financial problems,
domestic abuse).
During the consultation, knowledge of
some clues are helpful to suspect that the
patient may have a “hidden agenda”. They are:
™™ Body Language of patient—lack of eye
contact, nervous, embarrassed.
™™ Problem mention by patient is very trivial.
™™ Symptoms do not make sense/inconsistent
history.
™™ Characteristics of patient, e.g. teenager.
Hidden agenda often provide a clue to the
primary reason for patient’s visit. For example,
a male adult concerned with premature
ejaculation may complaining mainly of job
stress and may say at the end of consultation,
“By the way doctor, I am concerned about
my low sex; do you think it’s important?”; or
a patient with non-specific complaints may
state, “a friend of mine is diagnosed as cancer
of the liver; do you think that has anything to
do with my illness?” Similarly, a young patient
who knows of someone passing away of heart
attack may be anxious enough to seek help
when he has aches and pains in chest muscles
which he would have normally ignored. Since
he has now learnt from experience the link
between chest pain and death due to heart
attack, he may complain of only chest pain
(and not his worry about heart attack) and
leave the rest to the doctor to find its cause—
without disclosing his “hidden agenda ” of
possible heart attack.
Thus, because of the fear of rejection or
humiliation, patients may test physician with
some general complaints before mentioning
the specific reason, i.e. “hidden agenda”,
for their consultation. Hidden agenda can,
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therefore, be defined as, “the unconscious
motivations, fears, and beliefs that underlie the
patient’s request for a medical consultation”.
Unless the doctor is able to fathom these,
the patient may only be left with treat his
most obvious symptoms but not resolve the
underlying problem.
A thoughtful physician should pay
attention to these concerns. Further search
should be made for the underlying reason
for the visit when a patient presents with a
trivial complaint that appears inappropriate
at the time because it improves symptom
management and total treatment efficacy.
Therefore, it is a good practice to enquire if
there is anything the patient would like to add
before you finish by asking question such as,
“Is there anything else you want to tell me?”,
or “ What you think may be the problem with
you?. This may bring out the real reason for the
encounter, i.e. “hidden agenda.” (Table 12.3).
The patient usually has a long-standing list of
symptoms (‘shopping list’ of problems), with
non-organic pathology. Features that prompt
physician to probe to unmask the hidden
agenda are:
™™ Frequent attendance with minor illness.
™™ Frequent attendance with same symptoms
or multiple complaints.
™™ Attendance with a chronic illness, which
has not changed.
Table 12.3  Tips to uncover the hidden agenda
• Open consultation style; encourage the patient
to talk without interruptions, especially at start of
consultation.
• Give patient enough time, do not look hurried.
• Establish rapport, be empathetic, sympathetic
and show understanding.
• Summarize and reflect back to patient what has
been said.
• Pay attention to subtle cues and hints that the
patient may drop.
• Deal competently with trivial complaint if that is
all they tell you at first.
• Use non-verbal and verbal communication
skills to find patient’s ideas, concerns and
expectations.

™™ Fails to recover in expected time of illness,
injury, or operation.
™™ Failure of reassurance.
™™ Frequent visits by a parent with a child with
minor problems.
™™ Adult patient with many accompanying
relatives.
™™ Inability to make sense of the presenting
problems.
Most patients with hidden agenda are
young, undereducated, unmarried, who would
like to talk to a sympathetic doctor about
personal problems, not traditionally thought
of as medical problems.
Generally, psychosomatic illnesses, inter­
personal family conflicts, sexual dysfunctions,
STDs, substance abuse, cancer phobia and fear
of crippling diseases, such as stroke, arthritis,
etc. form the bulk of hidden agenda in patients
consulting their family physicians.21
Common Pitfalls when Interviewing
Patients
These are:
™™ Poor eye contact.
™™ Over reliance on notes.
™™ Over reliance on ‘systematic enquiry’ (i.e.
textbook teaching).
™™ Premature focusing down on the perceived
problem.
™™ Lack of clarification and/or precision.
™™ Failure to follow-up patient’s cues as to
what they think the problem may be (see
Table 12.2).
™™ Deficiencies in question style.
™™ Omitting to ask what the patients ideas are
about their problems.
Consultations as Routines, Dramas
and Ceremonies
An interesting way of viewing the consultation
process is to classify them into one of four types
by process. Miller describes these four types
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Chapter 12: The Consultation 113
as: routine, drama, transitional ceremony, and
maintenance ceremony.
Routines are everyday family practice
problems, e.g. acute infections, minor trauma,
need for reassurance, etc. These are dealt simply
by mutual agreement and resolve rapidly.
Dramas are encounters involving uncertainty,
conflict, and emotion, lack of common ground,
family discord, or diagnosis of an illness with
grave implications. The doctor converts the
drama, (e.g. an exited, or emotional patient, or
an unexpected behavioral event) to a transitional
ceremony (ref. next para), or refers the patient to
a colleague.
Transitional ceremonies are situations
where the purpose is to provide a transitional
explanation and protect the patient from
harm until a longer visit can be arranged.
Often, they unfold in the course of a routine
visit. The doctor’s aim in these cases is to
allow the drama to start and buy time. This is
accomplished by the following four steps: the
patient must know that the doctor believes him
or her; the doctor must address the patient’s
greatest fears; the doctor should perform some
physical examination; and give the patient
hope and something to do before the next visit.
One example is the abdominal pain that the
doctor does not detect anything serious but
the situation may still be too early to tell if it is
serious or not. The patient is told to observe
and report back if anything untoward happens
such as persistence or worsening of pain.
Maintenance ceremonies are consultations
that have settled into a regular, recurring
pattern. These may be dramas that have
resolved into a period of adjustment, visits
for control of a chronic disease, or a periodic
need for support and reassurance. Others are
visits that physicians find disturbing: patients
with chronic symptoms that do not respond
to treatment, people with self-destructive
tendencies, and those whose wants cannot be
satisfied. Ceremonies are so-called because
 114  Section 4: The Practice of Family Medicine
of their ritualized symbolic character. The
same ritualized conversation, examination, or
therapy may take place at each visit.
Patient Satisfaction with the
Consultation
The following are what patients judge to be the
most important elements in the consultation:
™™ Their “ICEs” are discussed and dealt with,
™™ That the doctor communicates warmth,
interest, and concern,
™™ The doctor volunteers information,
™™ The explanations are in terms understood
by them,
™™ Recall and understanding of what has
been said,
™™ Involvement of the patient in decision-
making,
™™ Patient’s understanding of health and the
factors involved,
™™ Patient’s personality and internal or
external factors affecting the personality,
and
™™ The patients own “Health Belief Model”,
e.g. social, psychological, superstitious
beliefs; motivation toward wellness or
illness; past experience with doctors, etc.
Troublesome Consultations22
Usually, consultations progress according to
the best-laid plans. Sometimes, in practice,
this is seldom the case. Several things can go
wrong with the consultation. Some common
difficulties encountered are:
™™ Problems created by being sick: Illness
or worry about potential illness causes
behavioral changes in the person. Factors,
such as, pain, fear, anger, frustration, denial
contributes to difficult consultation.
™™ Problems created by behavioral styles: A
lying, malingering, manipulative, drugged,
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demented, delirious patient situations in
which the consultation is flawed.
™™ Significant difficulties can be created
by differences in native language or
cultural practices between the doctor and
patient. The risk of misunderstanding and
misinterpreting information arises when
these differences exist.
™™ Problems created by situation or topic:
Direct information may not be available
in situations like in demented, drugged, or
critically ill patients. Details regarding risky
life style habits, such as sex, alcohol, etc.
may have to be obtained from third party;
e.g. a spouse, family friend, a care taker.
™™ Majority of troublesome consultations
can be surmounted by tact, patience,
experience, and above all by not forgetting
the human dimension of the encounter, i.e.
making a humanistic approach integral
and relevant to patient care that are likely
to improve clinical outcomes.
Conclusion
The consultation is the cornerstone of all
that we do in family practice. Information
gathering, relationship building, and patient
education are the three essential functions
of the consultation. A physician-centered
interview using a biomedical model can
impede disclosure of problems and concerns.
A patient-centered approach can facilitate
patient disclosure of problems and enhance
physician-patient communication. This, in
turn, can improve health outcomes, patient
compliance, and patient satisfaction and
may decrease malpractice claims. Physicians
can improve their consultation skills through
continuing education and practice.
Consultations are an important part of
medical practice. Treat patients as you would
like to be treated yourself. Be honest and
respectful and make this contact with them a
pleasure.23

References
1. Rosenberg EE, Lussier MT, Beaudoin C.
Lessons for clinicians from physician-patient
communication literature. Arch Fam Med,
1997;6:279–83.
2. Rich EC, et al. The diagnostic value of the
medical history. Perceptions of internal
medicine physicians. Arch Intern Med, 1987;
147(11):1957–60. [PMID: 3675097: Abstract].
3. Web site: http://www.skillscascade.com/
handouts/Models2003%20.rtf.Accessed on
06-02-09.
4. Consultation Analysis: Consultation models
– web site - http://www.patient.co.uk/doctor/
Consultation-Analysis.htm. Accessed on 15-
11-2011.
5. Helman, C.G. Culture. Health and Illness. 4th
edn., London: Arnold 2001.
6. Stott and Davies. The potential in each primary
care consultation – an aide me moiré. J RCGP,
1979:201.
7. McWhinney. Clinical Method. In: A Textbook
of Family Medicine (2nd edition). Oxford: 1997.
8. Patient-centered Medical Home. American
academy of Fam Phy. 2009.
9. Daaleman TP. The medical home: locus of
physician formation. J Am Board Fam Med.
2008;21(5):451–7. [PMID: 18772299: Free full
text].
10. What Is the Patient-Centered Medical
Home? American College of Physicians.
Web site - http://www.medscape.com/
viewarticle/589670. Accessed on 13-11-2011.
11, Rittenhouse DR, et al. Small and medium-
size physician practices use few patient-
centered medical home processes. Health Aff
(Millwood). 2011;30(8):1575–84. Epub 2011 Jun
30[PMID: 21719447: Abstract].
mebooksfree.com
Chapter 12: The Consultation 115
12. Rosenthal TC. The medical home: growing
evidence to support a new approach to primary
care. J Am Board Fam Med, 2008;21(5):427–40.
[PMID: 18772297: Free Article].
13. Pendleton D. Consultation analysis. Update
1987;34:803–7.
14. Carrillo JE, et al. Cross-cultural primary
care: a patient-based approach. Ann Intern
Med. 1999;130(10):829–34. [PMID: 10366373:
Abstract].
15. Hayes C, et al. A Whole-Person Model of Care for
Persistent Pain: From Conceptual Framework
to Practical Application. Pain Med. 2011. doi:
10.1111/j.1526-4637.2011.01267.x. [Epub ahead
of print][PMID: 22054224: Abstract].
16. Giessler A, et al. Compliance in the treatment
of schizophrenia – results of an expert survey
in Saxony and Saxony-Anhalt. Psychiatr Prax.
2005;32(7):349–57. [PMID: 16220419: Abstract].
17. Rosendal M, et al. Management of medically
unexplained symptoms BMJ, 2005;330:4–5.
18. Tuckett, et al. Eliciting patient’s beliefs
important to aid their understanding and
recall, 1985.
19. B Bub. The patient’s lament: hidden key to
effective communication: how to recognise and
transform. J Med Ethics; Medical Humanities
2004;30:63–69.
20. Rakel Robert e. Establishing rapport. In:Text
book of family medicine. Editor: Robert E.
Rakel. 6th edn. Chapter 18, p.271.
21. McWhinney. Clinical Method. In: A Textbook
of Family Medicine (2nd edition). Oxford: 1997
22. Willms JL, et al. Physical diagnosis: Bedside
evaluation of diagnosis and function. Williams
& Wilkins, 1994.
23. Bleker Otto P, Department of Obstetrics and
Gynaecology, Academic Medical Centre
Amsterdam, Amsterdam, Netherlands.
 13 The physician-patient
relationship

“Some patients, though conscious that their condition is perilous, recover their health
simply through their contentment with the goodness of the physician.”
— Hippocrates (460-377 BC)
“The essence of the practice of medicine is that it is an intensely personal matter.
The treatment of a disease may be entirely impersonal; the care of the patient must be entirely
personal. The significance of the intimate personal relationship between the physician and patient cannot
be too strongly emphasized…. in a large number of cases both the diagnosis and the
treatment are dependent on it.”
— John A Benson

Concepts and Changes During the last decade, in many parts of

The physician-patient relationship is one of the
most unique and privileged relations, based
principally on “knowledge, trust, loyalty, and
regard.”1 All over the world, this relationship
has been governed by the time-honoured
conventions and ethical principles—in ancient
times by classical Ayurvedic Senior Triad
Literature: the Charaka Samhita, the Sushruta
Samhita, and the Ashtanga Hridaya Samhita*,
and Hippocrates oath; and in recent times
by Medical Councils of respective countries
or guidelines, and recommendations by
international organizations like World Health
Organization and World Medical Association.
the world, the one-to-one physician-patient
relationship, which characterized the practice
of medicine, is in jeopardy, primarily because
of the growing complexity of medicine and
changes in the healthcare delivery system. 2
Escalating costs of health care, increasing
reliance on technological methods of diagnosis
and treatment, increased geographic mobility
of both patients and doctors, the growing
culture of “managed care” such as health
maintenance organizations, have blurred the
individual physician-patient relationship.1,3
The “internet” is rapidly changing the
physician-patient relationship. By providing

*The Samhita means compilation or collection. The Charaka Samhita is the earliest major medical text
of Ayurveda, attributed to the physician Charaka. Traditionally it is thought that he lived around 1000
to 800 B.C., but according to some Western scholars his period was around the first century AD. The
Sushruta Samhita is the major surgical text of Ayurveda, attributed to the physician Sushruta. It is the most
advanced compilation of surgical practices of its time. The exact period of Susruta is unclear but some
scholars put him at around 600 BC. Ashtanga Hridaya Samhita is the third major treatise in the Senior
Triad, attributed to Vagbhata. It is a concise version of the works of Charaka and Sushruta and possibly
his period was around AD 700.

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 Chapter 13: The Physician-Patient Relationship 117
access to medical information, online medical
advice, computer-based home-monitoring
systems, and online support groups, the
Internet is making it possible for patients to
assume much more responsibility for their
own health care. Patients present to the
physician with information from the Internet
about illness and treatment. The quality of this
information, at present, is extremely variable in
terms of its reliability and completeness. Some
information may be false and can actually be
harmful.
Further, an increasing tendency on the part
of patients to express their disappointments
with healthcare system by legal means
(medical malpractice suits) has given a legal
orientation to this relationship and various
legislations have been imposed with punitive
measures.
Modern medicine has increasingly been
seen in terms of human rights. Considering the
changing values of the society, technological
advances in healthcare system, as well as
the vulnerability of patients, maintaining the
humane qualities of medical care is a major
challenge (Table 13.1).
However, it has been felt by various ethical
medical organizations and committees
that, “doctor-patient relationships based on
openness, trust and good communication will
enable to work in partnership with patients to
address their individual needs.”4
There is also evidence to emphasize that
“a sustained relationship between a patient
and a physician is beneficial.” 5,6 From this
sustained relationship over time, other
attributes of primary care are thought to
arise, including trust, comprehensiveness
of care, interpersonal communication, and
accumulated knowledge of the patient by
the physician. These attributes of physician-
patient relationship are well articulated in
the famed statement by legendry Dr. Francis
Peabody, which was delivered more than half
a century ago:
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Table 13.1 Some changes affecting the physician-
patient partnership
• Rise of consumerism in medicine
• Shift of care from hospital to community
• Increased attention to prevention and patient
education
• Changing status of women in society
• Emphasis on patient autonomy
• Doctor’s role as trustee regarding disability
benefits
• Increased awareness of physician’s sexual abuse
of patients
• Increased hospital liability for doctor’s care
• Administrative, containment of medical care costs
• Increasingly litigious environment
• Increased use of technology
• Social acceptance of physician-assisted suicide
• Multiculturalism
• Social concerns about woman assault and
violence
• Holistic and alternative health movement
• Increased emphasis on informed consent
• Change in status of all professions in society—
decline of role of medicine and expansion in role
of other professionals
• Attacks on professional self-regulation
• The rise of a disabled culture of affirmative action
and pride
Source: Patient-centered medicine: transforming the
clinical method. Moira Stewart et al, Sage. 1995 ISBN
0-8039-5689–4.
“The significance of the intimate personal
relationship between physician and patient
cannot be too strongly emphasized, for in
an extraordinarily large number of cases
both the diagnosis and treatment are directly
dependent on it. One of the essential qualities
of the clinician is interest in humanity, for the
secret of the care of the patient is in caring for
the patient.”
Types
Historically, there are at least four types of
doctor-patient relationship described; namely:
autonomism, egalitarianism, paternalism, and
autocracy.7
™™ Autonomism (i.e. personal freedom):
The patient has the right to make
 118  Section 4: The Practice of Family Medicine
decisions regarding the health care that
is recommended by his/her physician.
Accordingly, patients may accept or
refuse any recommended medical
treatment. However, if the patient takes an
autonomous decision, the doctor needs to
understand the reason for such a decision
and may offer alternative considerations.
For example, if the patient requests a
second opinion, the doctor may agree if
it’s reasonable, but may resist if it’s deemed
unnecessary and not cost-effective.
™™ Egalitarianism (i.e. equal rights): It is a
situation where the patient is encouraged
to assume more responsibility in decision-
making. This is conceptually good for
the patient, especially in chronic illness.
However, the doctor needs to know that ill-
health can diminish autonomy and make
egalitarianism inappropriate.
™™ Pa t e r n a l i s t i c ( i . e. f a t h e r l y ) : T h i s
model involves patient’s dependence
on physician’s professional authority.
Believing that the patient would benefit
from the physician’s actions, a patient’s
preference are generally overridden
or ignored. Although paternalism is
traditionally frowned upon, yet it may
be appropriate if the patient is not in a
situation to decide because of inability to
understand or too young to decide.
™™ Autocracy (i.e. dictatorial): Although
viewed by many as unacceptable, yet it
may be necessary in medical, surgical, or
psychiatric emergencies.
These levels describe how the doctor and
patient relate to one another during their
negotiation. Teachers and learners can use
this model to describe how the doctor and the
patient affect the negotiation process, and how
the process in turn affects the doctor-patient
relationship and medical care.
During the second half of the 20th century,
the physician-patient relationship has evolved
toward “shared” decision making based on
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the concept of “partnership and collaborative”
efforts between the two (Table 13.2). This model
respects the patient as an autonomous individual
with a right to hold views, to make choices, and
to take actions on personal values and beliefs.
Patients have been increasingly entitled to weigh
the benefits and risks of alternative treatments,
including the alternative of no treatment (e.g.
do not resuscitate orders) and to select the
alternative that best promotes their values.
Scope of Physician-Patient
Relationship
The physician-doctor relationship paves the
way for frank discussion in which the patient’s
needs and preferences and the doctor’s clinical
expertise and knowledge are shared to select
the best treatment options.
In the present medical scenario the
scope of doctor patient relationship may be
summarized as below:
Establish Rapport (Implied Consent)
Patient must develop trust and faith in
his doctor before he reveals personal and
intimate information. Doctor’s humanistic
attributes as encompassing respect, integrity,
and compassion for the patient’s dignity,
irrespective of his socio-economic status,
genuineness in approach and positive regard
play crucial role in establishing the rapport.
Table 13.2 Partnership: Physician’s participation in
patient care
• Attends all patients with unconditional regard,
• Provides helping actions and communications
that are patient centered
• Negotiates patients’ choices, decisions, and
requests, including possible conflict in the
relationship
• Educates patients with respect to disease,
investigations, treatment compliance, and
prognosis
• Promotes health education and preventive life
style
 Chapter 13: The Physician-Patient Relationship 119
Be Attentive and a Good Listener
Attaching importance to even the most trivial
of the patient’s complaints; making the patient
feel that he is the most important person in
the consultation room, and his problems are
indeed most significant; only then the patient
feel relaxed and at ease with the doctor.
Avoid Interruptions
Patients should have a right to speak. Many
doctors make a diagnosis in a few seconds
and subsequently ask few questions related to
the possibility they have already considered.
Such an approach will miss vital information
for diagnosis and treatment. Open-ended
questions reveal more information than closed
ended questions.
Guide the Patient
Patients are not expert in giving history; they
need to be guided to enumerate all the relevant
details. Encourage the patient to focus on
one point at a time. Focus on specific details.
In certain situations the doctor should also
recognize the expertise of the patient.
Avoid Criticism
Never criticize your patients. Criticism leads
to drop-out and poor drug compliance.
Communication fails when patient fears that
his feelings and ideas will not be accepted.
Never argue with the patient when he relates
what may appear to be irrelevant, but which is
apparently important to the patient.
Avoid Emotional Reaction
Patient should be given freedom to express
their resentment and anger. This will enhance
adherence to treatment and follow-up visits.
For example, patient says, “I have been
following your advice since a month, but
I don’t feel any better.” Doctor might say,
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“so what...it is not my fault…you may go to
another doctor.” Patient will feel rejected and
there will be higher chances of dropouts.
Should there be a reason to disagree with a
patient’s opinion, be positive in presenting
your views without belittling the patient or
making him feel inadequate and ignorant.
Tact and dignified diplomacy are the keys to
a successful and long-lasting doctor-patient
relationship.
Avoid Parenting your Patient
Be firm and pleasant in your discussions
without being involved in patient’s personal
or family life. Also any attempt by the patient
to become personally involved with the doctor
should be discouraged.
Non-judgmental
Doctors should not express their personal
views on topics which might evoke emotional
reactions in the patient. Personal views on
caste, religion, politics, family relations,
financial status, etc. should not be discussed.
Be Gentle and Concerned when
Examining the Patient
Make the patient relaxed through every step of
the physical examination, periodically pausing
to explain the need for a particular step.
Explain the Nature of Illness
Many doctors do not explain anything about
the nature of illness, severity, causative factors,
treatment outcome and risks. Patients may
have many misconceptions about the causes
and treatment. These false beliefs need to be
addressed and rectified in order to enhance
treatment compliance. For example, a patient
of anxiety neurosis presents to a physician
complaining of palpitation, which he believes
to be due to a heart disease. He is examined
and prescribed medication (for anxiety)
 120  Section 4: The Practice of Family Medicine
without any information about the nature of
illness. Patient will go back with a firm belief
that he has a heart disease.
Be Clear and Discreet
Be clear and discreet when discussing possible
diagnosis, keeping the interest of the patient in
mind, without alarming or frightening him. It
is useful to be cautious and be guarded in what
should be revealed at every stage of the disease,
pending the outcome of investigations. The
doctor must keep in mind the mental state
of the patient, the gravity of the findings, and
wishes of the next of kin.
Avoid Presenting Yourself as an
Embodiment of Noble Profession
Avoid presenting yourself as an embodiment
of noble profession and giving the impression
that the patient has finally reached to the
ultimate healer.
Confidentiality
Medical confidentiality is a traditional and
an integral requirement of doctor-patient
relationship. Central to this principle is the
preservation of the dignity, privacy, and
integrity of the patient. The physician’s duty
to maintain confidentiality extends from
respect for the patient’s autonomy. When a
third party seeks medical information, such
requests should only be entertained on the
explicit written consent of the patient or the
next–of–kin.
Referrals
The doctor should himself be prepared to
initiate a referral to a colleague for a second
opinion when situation demands. The doctor
must make the patient understand clearly that
this is being done at the patient’s interest to
clarify areas of doubt. The doctor, giving the
second opinion must convey the same without
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prejudice and without any aura of superiority,
seniority or appearing to be more competent
than the principal doctor, and subsequently refer
the patient back to the principal doctor, with
suitable suggestions, preferably in confidence.
Relatives and Friends
Unknown to the doctor coming in contact
for the first time with the patient, there
are concerned friends and relatives in the
background. These people do not normally
appear in the beginning but decent soon after
their patient gets serious. They then have a
barrage of questions—why did it happen; will
the patient survive, etc. It is important for the
doctor to appreciate the influence and the
interest that these relatives and friends have
on the patient, and treat them with respect,
while taking pains to answer their questions,
however irrelevant or exasperating they may
be. Ambiguous or deliberately misleading
information may afford short-term benefits
while things continue to go well, but denies
individuals and their families opportunities
to reorganize and adapt their lives toward the
attainment of more achievable goals, realistic
hopes and aspirations. As Hippocrates states,
“I think the best physician is the one who has
the providence to tell to the patients according
to his knowledge the present situation, what
has happened before, and what is going
to happen in the future.”8,9 In the event of
unforeseen eventualities in the course of
patient management, it is this pleasant and
cordial line of communication that will most
often see the doctor through the crisis.
Non-verbal Aspects
These are as important as verbal messages.
The physical appearance of the doctor, in the
way of dressing, grooming, and presenting in
terms of cleanliness and personal hygiene,
are to the patient as important as the doctor’s
manners, confidence, and general composure.
 Chapter 13: The Physician-Patient Relationship 121
The doctor’s body gestures, voice tone and
volume, facial expressions, eye contact,
simplicity and good humor convened by a
smile or an empathetic laugh have their place
in the art of consultation. To the person who
is entrusting personal life and health, or that
of his loved ones, these aspects of external
presentation are manifestly as important as
the doctor’s intrinsic qualities and personal
capabilities…“for in the patient’s perspective,
the image of the doctor is cast in the mould of
physical and moral perfection.”
Closure
Before leaving the patient, the doctor should
carry out the following acts of closure:
™™ Ask the patient if there is anything else to
add or to ask. This is especially important
in individuals presenting with chronic
undifferentiated symptoms without
significant physical findings. A patient
may present with symptoms, such as
tiredness, lack sleep or appetite, which
may represent as a camouflaged, disguised
or hidden presenting symptom for the
real psychosomatic, behavioral, inter-
personal family conflicts, sexual, or drug
related problems. Poor self-esteem, fear
of malignancy or some other medical
catastrophe are just some of the reasons
patients present to doctors. Unless the doctor
is sensitive to the patient’s needs and listens
emphatically, and provides an opportunity to
communicate freely, these “hidden agenda”
are likely to be missed by the doctor. As John
Murtagh states, “The bottom line is that
patients are often desperately searching for
security and we have an important role to
play in helping them.”10
™™ Ascertain that any expectations on the
part of the patient have been clarified and
attended to, and
™™ Thank the patient for cooperation.
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Ending the Physician-Patient
Relationship11
Physicians enter into the physician-patient
relationship with a commitment to provide
their patients with quality service. However,
when circumstances affect the physician’s
ability to achieve this, he/she may decide to
end the physician-patient relationship. In
some cases, it may be the patient who decides
to end the physician-patient relationship.
Situations which may Result in a
Decision to End the Physician-Patient
Relationship
™™ Breakdown of trust and respect between
the physician and the patient. This may
occur when there has been:
ƒƒ Patient fraud, such as for the purpose
of obtaining narcotics or other drugs;
ƒƒ Serious threat of harm to the physician,
staff and/or other patients;
ƒƒ Other forms of inappropriate behavior
toward the physician, staff and/or other
patients;
ƒƒ A conflict of interest that compromises
the physician’s duty to put the interests
of his/her patients first;
ƒƒ A communication breakdown that makes
it impossible to provide quality care.
™™ The physician’s practice has become too
large to manage, resulting in increasing
pressure on both physicians and patients.
Situations where it is Inappropriate
for a Physician to End the Physician-
Patient Relationship
™™ The patient chooses not to pay professional
fees or annual fee
™™ Prohibited by the Human Rights Code
™™ As outlined in the regulation on pro­
fessional misconduct
™™ The patient chooses not to follow the
physician’s treatment advice
 122  Section 4: The Practice of Family Medicine
™™ The patient requires urgent or emergency
services not otherwise available.
Ending the physician-patient relationship
will usually have significant consequences for
the patient, as he/she will need to find another
health care provider.
Therefore, physicians should always
carefully evaluate any decision to discontinue
care and should use reasonable efforts to
resolve any issues affecting the relationship
with the patient prior to any final decision.
Reasonable efforts include discussing with the
patient, when possible, the reasons affecting
the physician’s ability to provide quality care
and/or the elements that are necessary for an
effective physician-patient relationship.
Conclusion
While historically doctors have bound
themselves by codes of conduct, the society’s
concepts of health care and its delivery systems
are rapidly changing. It is, therefore, important to
codify, define, and recognize the privileges and
rights of both the patient as well as the doctor.
While making such efforts, the doctor-
patient relationship must be based on
humanistic approach, faith, and confidentiality,
and should not be allowed to erode; rather
it should be strengthened by making it a
10. John Murtagh. In: Safe diagnostic strategy:
partnership and collaborative effort to achieve
cooperation of the patient and his relatives on
one end and the highest proficiency from the
11. Ending the Physician-Patient Relationship.
doctor and benefits of institutions on the other.
References
1. Ridd M, et al. The patient-doctor relationship:
a synthesis of the qualitative literature on
mebooksfree.com
patients’ perspectives. Br J Gen Pract. 2009;
59(561):e116–33. [PMID: 19341547: Free PMC
Article].
2. Harrison’s Prin. Of Int Med, 16th edn. vol.1: 1.
3. Herring B, et al. Using HMOs to serve the
Medicaid population: what are the effects
on utilization and does the type of HMO
matter?Health Econ. 2011;20(4):446–60. doi:
10.1002/hec.1602.[PMID:21394815:Abstract].
4. General Medical Council-Good Medical
Practice: Doctor-patient partnership. Web site:
Gmcuk.org/guidance/good_medical_practice/
relationships_with_patients_partnership.asp
(Accessed on 13-10-2011).
5. Parchman ML, et al. The patient-physician
relationship, primary care attributes, and
preventive services. Fam Med, 2004;36(1):22–7.
[PMID: 14710325: Free Article].
6. Sans-Corrales M, et al. Family medicine
attributes related to satisfaction, health and
costs. Fam Pract, 2006;23(3):308–16. Epub 2006
Feb 3. [PMID: 16461452: Free Article].
7. Botelho RJ. A negotiation model for the
doctor-patient relationship. Fam Pract, 1992;
9(2):210–8. [PMID: 1505712: Abstract].
8. Fallowfield LJ, et al. Truth may hurt but deceit
hurts more: communication in palliative
care. Palliat Med, 2002;16(4):297–303. [PMID:
12132542: Abstract].
9. Harrison’s Prin. Of Int Med, 14th edn. vol.1: 5.
General Practice. 1996. McGraw Hill Book Co.,
Sydney: 104.
Web site:
http://www.cpso.on.ca/policies/policies/
default.aspx?id=1592&terms=termination+o
f+doctor+patient+relationship (Accessed on
14-10-2011).
 14
“The core of every illness, physical as well as psychological, has a fundamental
wound—a struggle of inner conflict which seems insurmountable and which can generate
bitterness and rage, and the loss of the will to live...”
Introduction
Psychological disorders are highly prevalent
in general practice, although frequently
unrecognized and untreated, and may present
as either a primary disorder or as a comorbid
condition.1 Anxiety and depression can mimic
physical symptoms of comorbid illnesses, such
as diabetes, coronary artery disease, stroke,
cancer or their treatments, and consequently
emotional distress may not be detected. Many
patients in general practice may not reveal
emotional issues to their general practitioners
(GPs) as they believe it is not a GPs role to
help with their emotional concerns. The
prevalence of borderline personality disorders
(BPD) in primary care is higher than that
found in general community studies. Despite
availability of various pharmacological and
psychological interventions that are helpful
in treating symptoms of BPD, and despite
the association of this disorder with suicidal
ideation, comorbid psychiatric disorders,
and functional impairment, BPD is largely
unrecognized and untreated.2 These findings
are important for the primary care physician,
because unrecognized BPD may underlie
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Balint Group
—Michael Balint
difficult patient-physician relationships and
complicate medical treatment.3
Thus, in order to initiate prompt diagnosis
and treatment of psychological disorders, there
is considerable emphasis being placed on the
capacity of family doctors to recognize and
deal with psychological difficulties.4-6
Certain techniques such as active listening,
using open questions and emotional words,
responding appropriately to patients’
emotional cues, and a patient-centered
consulting style can assist in detection of
psychological disorders. Screening tools for
psychological distress and patient question
prompt sheets administered prior to the
consultation can also be useful.7
One method that has proved particularly
helpful for doctors to reflect upon their style of
relating to patients, to transform uncertainty
and difficulty in the doctor-patient relationship
into a greater understanding and meaning
that nurtures a more therapeutic alliance
between clinician and patient, to gain a deeper
understanding of patient’s psychological
needs, thus facilitating the understanding and
management of difficult cases and increasing
work satisfaction is the “Balint Group”.
 124  Section 4: The Practice of Family Medicine
Historical Origins8
Balint groups* take their name from their
originator, Michael Balint, a Hungarian
psychoanalyst and biochemist (1896–
1970), who along with his wife Enid, also
a psychoanalyst, worked in the Tavistock
Institute of Human Relations, UK, with a group
of social workers and psychoanalysts on the
idea of investigating marital problems. Michael
Balint became the leader of this group and
together they developed what is now known as
the “Balint group”. The first group of practicing
physicians was established in 1950.
The situation postwar in England has
been described in terms not dissimilar to
our own today—one of high demand for
mental health services and a shortage of
mental health resources. Many had served
in the armed forces and those that entered
or resumed general practice met a set-up
immeasurably less sophisticated than today.
Working single-handed was the norm rather
than the exception, and there was little
support from nurses, counsellors or deputizing
services. GPs were being called upon to offer
assistance to large numbers of patients with
psychological problems and were not feeling
equipped to do so.
In this context, Michael Balint was asked
to provide mental health training for GPs. His
original plan was to train doctors to handle
basic mental health problems by using
traditional methods of medical education–
lectures, tutorials, and case presentations.
However, he soon became dissatisfied with
this approach. He realized that problems
presenting to specialists like himself were
different from the “undifferentiated illnesses”
presenting to GPs, and he believed that the
only way to acquire the necessary clinical skills
was through experience, and reflection upon it,
learning to recognize the difficulties involved
*Ref. Appendix 5A (Ref. p. 399-401) and 5B (Ref. p. 402)
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and the methods of dealing with them. He
felt that a “group setting” in which GPs could
learn from each other, where each would bring
clinical material for discussion, and where the
doctors’ ways of working could be highlighted
and examined was the best way to achieve
these aims. The support mechanism afforded
by Balint groups was therefore timely.
Thus, Balint groups were developed by
psychiatrist Michael Balint—who worked
with GPs in London in the 1950s—to meet
the specific and unique needs of GPs. Since
then, the Balint group method has continued,
developed, and become internationally
recognized, with an International Balint
Federation and groups and societies in many
countries.9
Balint Groups
“Perhaps the essence of Balint Groups has
always been to share experiences and enable
people to observe and rethink aspects of their
relationships with patients and their work as
doctors.”
The Balint group is a group method of
training doctors, generalists or specialists, in
the doctor-patient relationship. It consists
of 6–12 doctors with 1–2 leaders and it meets
regularly. Meetings usually last for 1–2 hours
and the group continues for 1 or more years.
The method is that of case presentation without
notes. A doctor reports, as spontaneously as
possible, a case from his practice that poses
a problem. Participants and leaders then
help the presenter, by means of associations,
questions, and interpretations, to elucidate
the difficulties in the presenter’s relation with
the patient. The aim is to sensitize the doctor
to transference and counter-transference in
the “retroactive action” of the consultation, to
give the doctor psychotherapeutic qualities,
and thus to achieve a “considerable though

limited change in the doctor’s personality to
enable the doctor to better understand and
help patients.” 10
Balint Training
Balint group training is a well-developed
method of understanding the doctor-patient
relationship and learning the therapeutic
possibilities of communicating skillfully with
patients.
The participants bring problem cases for
discussion with their colleagues. Exploring
these cases in depth is the principal method.
The agenda for discussion at each meeting will
be formed by the cases which the participants
bring for discussion. Common and assorted
categories of issues are invited for discussion
(Table 14.1).11 These are regarded as problems
when they impede the successful management
of the patient and patient care, or interfere
with the degree of comfort the physician
experiences in practice as a family physician.
The extended group discussions create an
ongoing learning environment. This process
provides physicians with an opportunity
to repeatedly explore and validate their
perceptions of the emotional factors that
play a role in illness or interfere with their
successful management of the illness; to
Table 14.1  Common cases in Balint groups
• Patients with psychosomatic symptoms
• Patients with both physical and psychological
problems
• Difficulties in doctor-patient interaction
• Difficult situation involving third party such as
family member, insurer, employer, social services
• Patients with mental health problems
• Non-compliance
• ‘Heartsink’ patients
• Multiple referrals
• Demanding patients
• Child abuse
• Drug seeking behavior
• Life-threatening illness
• Dying patients
• Bereavement
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Chapter 14: Balint Group 125
become sensitized to the effects of emotional
factors and personality types on the doctor-
patient relationship; and to continuously
define their role as family physicians in the
context of exploring with colleagues a variety
of challenges (Table 14.2).
Balint group discussion stimulates
its members to examine their individual
approaches and circumstances and explore
alternative ways of responding. This method
is not a doctor therapy group, nor is it a
didactic seminar. The role of the group leader
is not to teach “content” or give advice, it is
rather to stimulate the participants to gain a
greater understanding of the doctor/patient
relationship and to expand their repertoire for
handling difficult situations.
Above all, the outcome of Balint training
is a synthesis of cognitive and affective
processing that leads the physician to a more
precise, empathic and practical understanding
of doctor/patient interactions and difficult
patients. The physician learns to be more
therapeutic in his or her relationship with
patients while, equally importantly, learns
a framework within which to view patients
and practice that leads to less frustration,
dissatisfaction with practice, and burnout
(Table 14.3).
Table 14.2  What happens in a Balint group?
• The leader asks “Who has a case?”
• The presenter who volunteers tells the story
of a consultation, this is not a standard case
presentation, but a description of what happened
between the doctor and the patient.
• It need not be long, complicated or exciting
but something that is continuing to occupy the
presenter’s mind. It may be puzzling, or has left
the presenter feeling angry, frustrated, irritated or
sad.
• The group discusses the relationship between the
doctor and patient and tries to understand what
is happening that evokes these feelings.
• The feelings which the patient evokes are
significant and may be reflected in the presenter
or in the group. This facilitates the understanding
of the patient.
All discussions within the group are confidential.
 126  Section 4: The Practice of Family Medicine
Table 14.3  What can a Balint group do?
• It provides an opportunity for doctors to reflect on
their work,
• It can provide an outlet for anxieties and
frustrations generated by their work,
• It can arouse a doctors’ interest in patients whom
they have previously found
• upsetting, annoying or “difficult”,
• It can open minds to other possibilities, both of
diagnosis and day to day management,
• The group provides support and improves
communication with patients and other professionals,
and
• It can improve job satisfaction, the patient’s
perception of care and help to prevent burn-out.
Balint Discoveries
Michael Balint published the results of the
earlist Balint groups in 1957 in his landmark
book entitled “The Doctor, his Patients and the
Illness.”12 Some of the key findings are as follows:
The Doctor as Therapy
By far the most frequently used “drug” in general
practice was the doctor himself. Balint coined the
term “drug doctor”, focusing attention on how the
doctor-patient relationship may be therapeutic
or have adverse effects. A good communication
and teamwork spirit between the doctor and
the patient leads to more accurate diagnosis,
better response to treatment, and rapid recovery.
Patient satisfaction is high and takes more
responsibility for improving their health. Balint
proposed that the doctor had a “placebo” effect,
meaning “I please you’—the pleasing aspects of
the doctor’s relationship works for the patient’s
well-being.
The Diagnostic Process—Multiaxial
Diagnosis*
Doctors commonly have a fairly rigid protocol
for making a diagnosis, one that implicitly
*Multiaxial diagnosis using the DSM IV consists of five axis models, designed to provide a comprehensive
diagnosis that includes a complete picture of not just acute symptoms but of the entire scope of factors
that account for a patient’s mental health. (Ref. web site - http://mh4ot.com/2012/10/16/multi-axial-
diagnosis-using-the-dsm-iv/. (Accessed on 06-04-2015)
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ranks diseases (and therefore also patients)
in an order of supposed importance. In this
ranking, psychological problems are often
ranked lower and considered less important
than physical diseases.13,14
This ranking methodology often results in
the referral of difficult-to-diagnose patients
to a specialist. While providing relief for the
GP, this action, Balint showed, could lead
to a “dissipation of responsibility” such that
important clinical decisions were made
without anyone openly taking responsibility,
and no one taking responsibility for the “whole
patient”—what Balint called a “collusion of
anonymity”—created by the involvement
of multiple specialists where no one doctor
carried overall responsibility.
Clinical enquiry is often superficial and
diagnosis simplistic. Balint introduced the idea
of “levels of diagnosis”, whereby doctors were
encouraged not to make just a physical diagnosis,
but to consider what else might be going on, and
to make a “multiaxial” diagnosis.*
Balint group is specifically focused on
uniqueness of the general practice setting so
familiar to GPs: symptoms which are not part of
a recognized disease entity, complex mind-body
interactions, difficult patients whom specialists
can’t help, time constraints, and patients
who don’t comply with treatment. The Balint
approach focuses on these types of difficulties
rather than on specific diagnoses, seeking to
understand the meaning of a patient’s behavior
and symptoms. Without this understanding,
there are many patients who are difficult to
help. Conversely, there are many patients
who, with this understanding, are ideally
helped in a general practice context with its
advantages of continuity of care, integration of
the psychological and the physical, and the GPs
knowledge of family and community.

By including features of the patient’s
personality, relationships with family
members and others, the resulting overall
diagnosis provides a more embracing
overview of the individual’s physical and
emotional conditions. It has greater ongoing
validity in description and of usefulness for
treatment by centering upon the patient as an
individual whose conflicts and sufferings are
felt and understood. It may require lengthy
interviewing, but this may be shortened in
practice by focusing upon the particular aspect
of the patient’s world which seems central to
the pathology.15
Advice and Reassurance
G e n e ra l p ra c t i t i o n e r o f te n re s o r t t o
“commonsense” advice, or at other times
reassurance. Although, there may be nothing
wrong with such interventions, the fallacy
behind them is the belief that , “an experienced
doctor had acquired enough well proved
‘commonsense’ psychology to enable him
to deal with his patient’s psychological or
personality problems even without attempting
a full diagnosis.” While reassurance can at
times be beneficial, it is often inadequate and
administered prematurely.
Influence of the Doctor on the
Diagnosis
Doctors commonly believe that their approach
to patients—the customary stepwise diagnostic
process—is purely to make a correct diagnosis
and does not of itself influence the patient. The
research of the Balint groups contradicted this.
Balint showed that GPs had very individual
attitudes to patients, expectations of them
and ways of dealing with them—ways shaped
by their personalities and beliefs. These could
include a belief of how much suffering a
patient should endure, or a moral stance about
psychological problems or the meaning of
pain. Patients become educated to what their
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Chapter 14: Balint Group 127
doctor expects of them and this determines the
way in which they seek care and relief when
distressed.
Furthermore, when a stressed patient first
presents, their complaints are often physical, ill
defined, and not yet “organized”. What a doctor
does in this situation is critical in shaping the
subsequent course of events.
Patients often present various complaints
and the doctor has to analyze them legitimately.
If the doctor misses the underlying distress
and the complaint for what it is—an appeal for
care—there is a risk of creating an “illness.” The
doctor’s capacity to be in touch with the distress
is crucial. A premature diagnosis can be hard
to shift and may leave patients not getting the
help they need. And as Balint quoted, “a great
number of people have lost their roots and
connections... the individual thus becomes
more and more solitary, even lonely... any
mental or emotional stress or strain is either
accompanied by, or tantamount to, some bodily
sensation... one possible outlet is to drop in to
one’s doctor and complain... and it is here, then,
that the doctor’s attitude about how to prescribe
himself to the patient becomes decisive.”16
“The opposite danger however, is also
present. The doctor might be tempted to brush
aside all physical symptoms and make a bee-
line for what he thinks is the psychological
root of the trouble. This kind of diagnostic or
therapeutic method means that the doctor
tries to take away the symptom from the
patient and at the same time to force him to
face up consciously to the painful problems
possibly causing it. In other words, the patient
is forced to change his limited symptoms back
into the severe mental suffering which he
tried to avoid by a flight into a more bearable
physical suffering.”16
The Doctor-Patient Relationship
Although, Balint’s early groups began by
exploring the problems with which patients
 128  Section 4: The Practice of Family Medicine
presented and the diagnostic process
undertaken by the doctors with a view to
incorporating psychological techniques into
general practice, the focus came more and more
on the quality of the doctor–patient interaction.
Knowledge about diagnosis and treatment
is necessary but not sufficient for good clinical
practice. Because a Balint group is specifically
focused on general practice, it takes seriously
the uniqueness of the general practice setting
which creates the particular challenges so
familiar to GPs: symptoms which are not part
of a recognized disease entity, complex mind-
body interactions, difficult patients whom
specialists can’t help, time constraints, and
patients who don’t comply with treatment
The Balint approach focuses on these types of
difficulties rather than on specific diagnoses,
seeking to understand the meaning of a
patient’s behavior and symptoms. Without
this understanding, there are many patients
who are difficult to help. Conversely, there are
many patients who, with this understanding,
are ideally helped in a general practice with
its concept of continuing relationship with
patients, families, and community. Over time,
the relationship builds with every experience
shared—be it an experience of uncertainty,
frustration, or satisfaction. Balint likened it to
a “mutual investment fund.”* Every encounter
builds the investment. A further characteristic
is the variety of forms the doctor–patient
relationship can take. The doctor can be
consulted for a range of problems, see other
members of the family, or do a home visit.
This intimate yet varied knowledge means that
patients have many opportunities to discuss
issues of a psychological nature. This special
relationship is relevant when we consider the
*The mutual investment fund—All the shared experience and trust that doctor and patient accumulate
over many years in general practice can be used to encourage patients to try interventions which previously
they would not have considered.
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role of GPs in counseling. Patients will return,
and psychological work can continue at a pace
determined by the patient.
Thus, Balint came to see the doctor–
patient relationship (consultation style) as
the most potent, and most often prescribed,
therapeutic tool. What makes for a good
doctor–patient relationship, and how its
therapeutic effects can be maximized and
adverse effects minimized, became the central
question and focus of Balint groups.
Conclusion
Balint groups are an effective way for GPs to
think about their work in a way that leads to
increased self-efficacy and reduced strain.
An essential aim of the Balint approach is to
increase the confidence, competence and
satisfaction of the GP in his/her ordinary
work—to feel more at ease with patients
and with themselves as doctors, so that they
can help their patients more constructively
and with less stress. “With expanding breath
and depth of scope of family practice, how
are young family physicians to distill for
themselves a realistic and personal role as
family physicians? Balint groups are one venue
in which the family physician may explore and
experiment with role clarification in the quest
of a more humane and effective practice.”17 No
attempt is made to reconstruct the doctor, but
to help them to use their capabilities to the
best advantage. Many GPs grow personally
and professionally as a consequence of their
participation in a Balint group, and become
more effective and content in their work. These
outcomes are most needed to deal with the
increasing burden of psychological problems
in general practice.

References
1 Ansseau M, et al. High prevalence of mental
disorders in primary care. J Affect Disord. 2004;
78(1):49–55. [PMID: 14672796: Abstract].
2. Nock MK, et al. Cross-national analysis of the
associations among mental disorders and
suicidal behavior: findings from the WHO
World Mental Health Surveys. PLoS Med.
2009; 6(8):e1000123. Epub 2009 Aug 11. [PMID:
19668361: Free PMC Article].
3. Sansone RA, et al. Borderline personality: a
primary care context. Psychiatry (Edgmont).
2004;1(2):19–27. [PMID: 21197375: Free PMC
Article].
4. O’Connor EA, et al. Screening for depression
in adult patients in primary care settings: a
systematic evidence review. Ann Intern Med.
2009;151(11):793–803. [PMID: 19949145:
Abstract].
5. Pignone MP, et al. Screening for depression in
adults: a summary of the evidence for the U.S.
Preventive Services Task Force. Ann Intern
Med. 2002;136(10):765–76. [PMID: 12020146:
Free Article].
6. Verhaak PF, et al. Patients with a psychiatric
disorder in general practice: determinants of
general practitioners’ psychological diagnosis.
Gen Hosp Psychiatry. 2006;28(2):125–32.
[PMID: 16516062: Abstract].
7. Ryan H, How to recognize and manage
psychological distress in cancer patients. Eur
J Cancer Care (Engl). 2005;14(1):7–15. [PMID:
15698382: Abstract].
mebooksfree.com
Chapter 14: Balint Group 129
8. Clarke D, et al. Balint group-Examining the
doctor patient ralationship. Aust Fam Phy.
2002;31(1):41–4.
9. Web site - http://www.balintinternational.
com/membercountries.html (Accessed on
15-10-2011).
10. Balint, Michael. (1957). The doctor, his patient,
and the illness. New York: International
Universities Press.
11. Balint groups—An Australian perspective.
We b s i t e : h t t p : / / w w w . r a c g p. o r g . a u /
Content/NavigationMenu/PracticeSupport/
Consultingskills/BalintGroups/default.htm
(Accessed on 15-10-2011).
12. Balint M. The doctor, his patients and the
illness. London: Pitman Medical, 1957.
13. Klapow J, et al. Psychological disorders and
distress in older primary care patients: a
comparison of older and younger samples.
Psychosom Med. 2002;64(4):635–43. [PMID:
12140354: Free Article].
14. Jackson JL, et al. Outcome and impact of
mental disorders in primary care at 5 years.
Psychosom Med, 2007;69(3):270–6. Epub 2007
Mar 30. [PMID: 17401055: Free Article].
15. Clyne MB. The doctor-patient relationship
as a diagnostic tool. Psychiatry Med. 1972;
3(4):343–55. [PMID: 4679752].
16. Dr. med. Heide Otten. Balint work leads to Psy­
chosomatic thinking and is an advantage to the
well-being of patients and doctors. Vienna, 2002.
17. Johnson AH. The Balint Movement in America.
Fam Med, 2001;33(3):174–77.
 15 DESIGNING A PATIENT-
FRIENDLY PRACTICE

“Designing a patient-friendly practice doesn’t have to

cost you a lot of money or time or cause you a moral dilemma. It is simply a means
for letting patients know that you are willing and able to care for them.”

Introduction the dangers that can result from the health-

care environment. This report, fueled by the
Family physicians (FPs) and general
need for new facilities to be constructed, led
practitioners (GPs) in the 21st century are
to an explosion of research that now links
facing great challenges. The expectations
the physical structure and design of health
of patients, the interest of stakeholders,
care facilities to the health and well-being of
the media, the impact of new information
patients, nurses, other health care workers,
technology, and with the entry of healthcare
and visitors. This report implicated three major
management organizations, insurance
categories of outcomes that have an impact
companies, and the threat of corporate multi-
by evidence-based design: stress reduction,
specialty hospital practice looming large on
safety, and overall health care quality and
the horizon, family physicians and general
ecology.2
practice is truly at a crossroads.
Therefore, GPs have to bear in mind
However, GPs must adapt and grow to
the requirements of patients—to build and
meet new challenges. To bring about a radical
maintain their physical aspects* of practice
change in the quality, organization, and
to cater to their needs, and develop practice
delivery of services, general practices need to
activity, philosophy and culture that satisfy
redefine their roles.
the desires of patients and staff who work in
The vast majority of GPs believe that
office. By developing such a culture, GP can
they can achieve excellence in their practice
build, support and maintain the practice style
when they have developed the optimal mix of
they prefer, even in the face of competition.3
knowledge, experience, skills, attitudes, and
effective consultation techniques. Unfortunately,
what many GPs appear to forget is that the Objectives to Redesign
consultation, the very heart of their clinical Evidence shows that for GPs to provide high
practice, happens within a physical space.1 quality general practice, including quality
Further, a 2001 Institute of Medicine report of the interpersonal relationships between
captured the nation’s attention regarding the people involved, and the quality of the

*In a general practice, “physical aspects” includes the building and its site, all of the rooms and spaces in
the building, and all of the physical components in these rooms and spaces.

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 Chapter 15: Designing a Patient-friendly Practice 131
amenities needed to provide such care,
practice nurses, practice managers and
other practice staff are valuable resources.
Further, the provision of quality care must
be supported by appropriate infrastructure,
such as telecommunications, information
technology, clinical technologies (such as
those used in pathology and other diagnostics)
and other facilities relating to architecture,
reception, accessibility, and communication.
Some evidence also suggest that patients
differentiate doctors on the basis of their
manner, style of punctuality, location of
consulting rooms, attitude of reception staff,
ambience and caring atmosphere.4,5
In view of the above patient-specific and
rewarding criteria, it is essential that the
traditional physicians’ need to offer more
than their competitors for their survival. “In
today’s medical marketplace, patients see
themselves as consumers of healthcare with
certain customer-service expectations. The
medical practice that is indifferent or resistant
to these changes is at risk. Having a good
understanding of “patient-friendly changes”
can help a practice survive in a changing
environment. A patient-friendly office will
continue to meet the needs of the patient by
adopting this new practice style.”6
One of the many approaches to achieve
patient satisfaction is to build “patient-friendly
practice”, incorporating therein an aesthetic
architecture with administrative facilities,
which facilitate improved communication,
maintain hygiene and easy accessibility.
Operationally, service-excellence initiatives
will have a profound impact on patient
retention and new referrals, and possibly a
reduction of litigious risks. 7
Designing the Clinic
The clinic is the place where the doctors spend
a significant portion of their working life. The
working conditions and the environment in the
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clinic directly affect the way the doctor and staff
interact with patients and their families. At the
end of the day, it also has an influence on one’s
productivity, physical and mental well- being. It
is a good reason, therefore, to be very methodical
and careful about its functionality and décor.
To plan a clinic effectively, the designer
should have a thorough understanding of the
functional and aesthetic requirements of the
client, followed by an in-depth evaluation
of the possibilities and constraints of the
given space. Before doing anything to change
office’s design, it’s important to plan how to
make office processes more efficient, cost-
effective, and patient-friendly. Without this
conceptual foundation, ones approach to
physical redesign may end up in an outmoded
and wasteful exercise.
A clinic should ideally have enough space
not merely to seat its patients, but to locate
ancillary and support services—from the
stately reception counter to the humble pantry.
In addition, it should provide for circulation
and free movement between these areas with
adequate access to stairs and fire escapes.
When planning a given space, it is important
to conceive a long-term master plan, keeping in
mind planned growth and future requirements,
even if the intention is only to implement part
of the plan now and execute the rest as need
arises. The master plan would ensure that what
is installed now will not have to be dismantled
or relocated when new developments take
place. This would help eliminate wastage of
material and labor.
The Waiting Room and Reception
Creating a comfortable, practical waiting room
is a science unto itself. Many patients tend to
judge doctors by the quality of doctor’s waiting
room; therefore, a clean, well-organized front
desk and reception area will go a long way
toward creating a positive impression and
making patients feel comfortable.
 132  Section 4: The Practice of Family Medicine
Patients should see the receptionist
counter as soon as they come in, so they don’t
feel lost. In turn, the receptionist should be
able to see all patients no matter where they’re
seated, so nobody is forgotten.
The front desk should be configured to help
receptionist efficiently perform duties. Various
stationery items repeatedly used should be
readily available. Computers must be suitably
placed so that its screen is not visible to anyone
but the staff. The reception telephones should
be closely set with the conversation not audible
to those waiting. A separate telephone may be
dedicated totally for the use of patients for their
urgent needs. Availability of fax and photocopy
equipments to copy insurance cards, driver’s
license, referral letters, lab reports, etc. will
further enhance efficiency and fool proof
documentation. The station responsible for
collecting payments should have a cash drawer
and credit card machine available.
Furnishings should convey affluence, but
not opulence. Patients appreciate adequate
seating, comfortable ambient temperature,
and something to occupy while they wait. They
also do not wish to be infected while waiting;
patient and receptionist education about
separating children and adults from possible
infectious diseases helps enhance the doctor’s
reputation as a healthy practice.
The practice waiting room and its
facilities need to be visibly clean, tidy and
well maintained. It should be illuminated
sufficiently for casual reading. A few simple
paintings, photographs, health education and
health promotion posters add to the general
pleasantness of the room. A separate place
for storing safe drinking water accessible to all
patients should be provided. This is very much
desired by patients when there is a long waiting
at the clinic. One may also provide soothing
music and/or a TV which help patients their
waiting bearable. A notice board, placed
prominently, displaying important events,
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that are updated periodically is beneficial to
all visitors.
The Consultation Room
It should be roomy, neat and tidy, soothing to
the eyes and pleasant to the nose.
The examination table and the doctor’s
desk and chairs should be arranged in a way
that facilitates free communication and proper
physical examination. A curtain, which can be
drawn across to provide privacy is an essential
requirement. Soundproofing is essential for
patients’ trust in the confidentiality of the
practice.
It is acceptable to display certification or
scrolls of recognized medical degrees and
diplomas in the consultation room so that the
patient is fully aware of the credentials of the
doctor.
Clinical equipment should be in good
working condition and clean and neatly
arranged.
A sink and a clean hand towel within reach
will reflect a hygienic practice.
The presence of a computer screen appears
not to daunt a majority of patients. Patient
acceptance of computer use in medicine is, in
general, quite good. In addition, no consistent
decrease in perceived quality of care or increase
in physician-patient indiscrimination was
identified as a consequence of such computer
use. It was also noted that computer use by
physicians during clinical encounters does
not increase post-consultation patient stress.8
However, when entering data in the computer,
the physician is not making an eye contact
with the patient or observing the patients’ body
language, which clearly decreases the quality
of overall encounter. Further, some studies
indicate that while computer use by physicians
during clinical consultations may have an effect
upon many areas of the physician-patient
relationship (e.g. confidentiality), the individual
 Chapter 15: Designing a Patient-friendly Practice 133
personalities of the physicians involved appear
to play an even greater role.9
Staff
The front-office staff and the reception area
represent the first and last impressions that
patients will have of a practice on any given visit.
These impressions endure, and in many cases
they shape the patient’s perception of the doctor.
It’s therefore critical to the success of doctor’s
practice that these be good impressions.10
Besides being knowledgeable about the entire
working of the office system, the doctor’s
schedule and the responsibilities of the other
staff, the front-office personnel should have
the ability to project the specific image of the
doctor’s working philosophy and culture* and
provide standards to support it, and it is vitally
important that these standards are maintained
and supported by the rest of the office team.
They must also take care to avoid destructive
and disruptive behaviors and conditions such
as noise, interference, excessive repetition, long
waits, appointment delays, and staff rudeness.
Staff should arrive at the office at least
fifteen minutes before the first scheduled
appointment. This is a good time to hold an
informal staff meeting to discuss the upcoming
days appointment, open slots, special meetings,
emergency calls, potential problems, as well as
reviewing previous day’s records.
The day’s list of scheduled patients and
appointment times should be prepared and
kept ready for the receptionist as each patient
arrives. The front desk staff should be ready
to turn their undivided attention to the first
patient as he or she opens the door.
The nursing staff must be neatly dressed,
courteous and sympathetic in their handling
of the patient and accompanying persons.
*Work culture is a combination of qualities in a doctor’s organization and office staff that arise from what is
generally regarded as appropriate ways to think and act. Work culture is the vehicle through which individuals
coordinate their activities to achieve common goals and expectations. (e.g. What are the organizations values?
How are decisions made? Which behaviors are encouraged? Which are prohibited? etc.)
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They must be efficient and be able to prioritize
patients and their problems, so that the doctor
will be able to see more ill patients earlier.
Greeting Patients—Checking-in
and Checking-out
A friendly, attentive receptionist can reduce
the anxiety of a doctor’s appointment.
Be the first to say hello. Everyone in the
practice should take the initiative in greeting
patients. Use the patient’s name whenever
possible, maintain ‘eye contact’ while speaking
and ‘listen attentively’ to patients.
The receptionist and/or staff should greet
each patient by name. For new patients,
an appropriate greeting could be: “Hello,
you must be Mr/Mrs ……….. I am .…… It’s a
pleasure to meet you. The doctor will be with
you shortly. Please make yourself comfortable
in the reception area.” Greeting the patient
personally is preferable to a sign that says,
“Sign in please and sit down.”
Patients requiring special assistance
should be escorted to a seat in the reception
area and then to the examination room.
The receptionist or the other staff should
politely verify the name, address, telephone
numbers, insurance coverage, referral letters,
previous health records, payment bills, etc.
with the patients or their family members.
Checking out also provides an important
impression for patients. It is everybody’s
wish that the patient leaves the office with a
favorable impression of the practice. Before
the patient leaves, ask if there is anything else
you can do. Conclude the visit by thanking
the patient and, if appropriate, relaying your
concern for his/her wellbeing (“Thank you, I
hope you’ll be feeling better soon.”)
 134  Section 4: The Practice of Family Medicine
If a follow-up appointment or referral letter
is needed, it should be handled immediately.
Proper referral letters and telephone numbers
and directories should be provided if the
patient has to be sent to a hospital or lab for
tests. The staff should politely check with
the patient that all payments are collected
as per the practice procedure and receipts
endorsed. An extra effort to arrange for
suitable transportation of needy patients and
a cheerful word of assurance and thank you is
the hallmark of best health practice.
Because check-in and check-out process
have so many components, they need to be
reviewed and updated periodically. Regular
staff meetings about the welfare of the staff,
their views, resolving problems, changes in
insurance policies, updating health code
numbers, physician delays, and the like have
to be resolved within the practice policy. As
new problems arise, the entire staff can work
on providing a solution.
Incorporating New Technology
Patient Education
Patient education boosts patient satisfaction
and reduces medical errors. Besides the posters,
books, pamphlets and handouts regarding health
information, we now have audiotapes, videotapes
and CDs suitable for patients’ education. Even
a suitable lending library with a deposit can
be set up. A card file kept in alphabetical order
with relevant details entered facilitates to recall
precious resources when needed.11
Patient Information
A computerized patient information system
promotes clinical safety and cost containment.
It allows interactive online consultations, clinical
cross-checking, the production of computerized
reports and schedules, fast response to laboratory
results, and safer drug administration, all of which
help improve the quality of care.
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Online Appointments and Consultation
Some e-health portals are offering services that
permit patients to make their own appointments.
If this option is employed, it is important to
ensure that those patients who do not have
access to the internet have equal priority to
doctor’s appointments. Many e-appointment
systems have specific protocols (e.g. registration,
instructions how to register, etc.) which need to
be read and agreed before any appointment is
processed, and misuse or abuse of such facility
can revoke ones access to such systems.
Recalls
Providing recalls/reminders for follow-up of
patients’ prognosis of disease is an important
aspect in healthcare practice. This can be done
manually but may be time consuming. With
increasing use of computers, practices can
provide recalls for services like vaccination,
screening procedures, hypertension, diabetes,
Pap smear, etc.
Build a Website
A website is a great way to reach people
worldwide—24 hours a day, 7 days a week. A
website can give the right kind of exposure to
doctor’s practice by incorporating therein every
bit of information and services that are provided.
It therefore makes a very good marketing tool.
The only thing to make sure is that the host
provides very good support system.
Conclusion3
Increasing consumer activism has been a
feature of last part of the 20th century. Patients
demand clinical and technical competence for
medical profession, but also highly rate quality
service and good interpersonal skills. Patients’
satisfaction has become central to many health
services both in the private and public sector.
The challenge now is to establish a
partnership, which will work cooperatively
 Chapter 15: Designing a Patient-friendly Practice 135
to create the patient-friendly family practice.
This will ensure not only our financial viability,
but also professionally satisfied doctors and
patients who can take an active role in the
maintenance of their own health.
References
1. Ruga W. Your general practice environment
can improve your community’s health. Br J Gen
Pract. 2008;58(552):460–2. [PMID: 18611310:
Free PMC Article].
2. C e s a r i o S K . D e s i g n i n g h e a l t h c a r e
environments: Part I. Basic concepts, principles,
and issues related to evidence-based design. J
Contin Educ Nurs. 2009;40(6):280–8. [PMID:
19639918: Abstract].
3. Mann L, et al. Designing a consumer friendly
practice. Aust Fam Physician. 2001;30(3):241–4.
[PMID: 11301762: Abstract].
4. Beaton G. Marketing in medical practice. Aust.
Fam Phy. 1987;16(10):1506–9.
5. Brown KK, et al. Impacting patient outcomes
through design: acuity adaptable care/
mebooksfree.com
universal room design. Crit Care Nurs Q. 2006;
29(4):326–41. [PMID: 17063100: Abstract].
6. Dooley SK. The patient-friendly practice. J
Med Pract Manage. 2006;21(6):358–61. [PMID:
1683307: Abstract].
7. Lasserre C. Fostering a culture of service
excellence. J Med Pract Manage. 2010;
26(3):166–9. [PMID: 21243888: Abstract].
8. Legler JD, et al. Patients’ reactions to physician
use of a computerized medical record system
during clinical encounters. J Fam Pract. 1993;
37(3):241–4. [PMID: 8409874: Abstract].
9. Garrison GM, et al. 21st-century health care:
the effect of computer use by physicians on
patient satisfaction at a family medicine clinic.
Fam Med. 2002;34(5):362–8. [PMID: 12038718:
Abstract].
10. Hertz KT. Front office: asset or liability?
MGMA Connex. 2004;4(9):2. [PMID: 15379207:
Abstract].
11. Helwig AL, et al. An office-based Internet
patient education system: a pilot study.J Fam
Pract. 1999;48(2):123–7. [PMID: 10037543:
Abstract].
 16
“When we turn to one another for counsel we reduce the number of our enemies.”
Introduction
Now, at the dawn of the third millennium,
non-communicable diseases (NCDs) are
sweeping the entire globe. 1 Today’s major
health problems are increasingly the result
of NCDs such as cardiovascular diseases,
ischemic strokes, chronic respirator y
diseases, diabetes and some cancers. 2,
3
Overweight and obesity are common
precursors and risk factors often called as
lifestyle diseases—diseases of affluence or
excess. That terminology suggests that people
adopt unhealthy habits—such as energy-
dense diets, smoking, and reduced activity
level—from personal preference and related
to individual’s behavioral patterns, and life-
long personal habits that have developed
through the processes of socialization. The
latest World Health Organization data paints
a worrying picture. At present, out of every
10 deaths in urban India, eight are caused by
NCDs. In rural India, six out of every 10 deaths
is caused by NCDs. Dr. Nata Menabde, WHO
representative to India, states, “Globally,
60% of the deaths are now caused by NCDs.
Similar are the numbers in India. NCDs are
affecting the entire globe. If not controlled,
they will become a tsunami that will not only
kill people but impair development and crash
economies.”4
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COUNSELING SKILLS
—Kahlil Gibran
Counseling Interventions in
Primary Care
Since mortality and morbidity due to NCDs
continues to increase, their prevention at all
levels—primary, secondary and tertiary—
requires a broad range of integrated, population-
based interventions, as well as measures
focused on individuals at high risk, including
the guidance and support from the physician.5,6
Individuals and patients must take responsibility
for following their day-to-day preventive
behaviors, report their progress to the physician,
and discuss health related problems. While
physicians cannot fill all the educational needs,
they can be pivotal in starting and guiding the
process.7 There is good evidence from high
quality studies that physicians can change
patient behavior through simple counseling
interventions in the primary care setting.8-14
Several general points have emerged from
these and other studies of effective counseling
to change behavior, which can be incorporated
into strategies for effective patient counseling
with its subsequent impact in reducing mortality
and morbidity from NCDs.15-17
Counseling
In the clinical context counseling can be
defined as—“the confidential therapeutic
 Chapter 16: Counseling Skills 137

dialog between a patient and a physician, Communication Technique

aimed at enabling the patient to explore the Attentive Body Posture and Languages
nature of his/her problem and take personal,
™™ Speaking audibly, clearly, and slowly
realistic decisions relating to health problems,
™™ Maintaining eye contact, but not staring look
in such a way that he/she determines his/her
™™ Nodding and other expressions to convey
decisions about what to do, without direct
understanding
advise from the councillor.” It enables the
™™ Reassuring by using terms,”I understand”,
patient to solve his/her problems—personal,
“Is it so?”
social, or psychological—through a special
™™ Asking effective questions
therapeutic relationship with the physician,
™™ Reflective listening—giving feed-back to
who provides contactual information,
the individual
education and psychological support and
™™ Identify feelings by statements, “I think you
allows patient to take decisions that facilitate
are upset/angry.”
coping preventing behaviors.
Counseling is concerned with individuals, Appreciate Use of Silence
couples, families and groups. Counseling ™™ Sometimes silence can mean more than
means choice, not force, not advice. A physician spoken words. It means the person needs
may think that his or her advice seems more time to understand and reflect
reasonable, but it may not be appropriate to information.
the particular circumstances of the patient
receiving the advice. With counseling, it is the Using a Language Person Understands
patient concerned who takes the decision so and Paraphrasing
that the solutions adopted are more likely to
™™ Use same language, avoid technical words,
be appropriate. An appropriate solution will be
and keep checking whether the person
one that the patient can independently follow
understands.
with successful results.
Thus, the basic aims of counseling include: Conveying Acceptance (being Non-
™™ To help patients gain an insight into the judgemental)
origins and development of emotional ™™ Make the person feel that intimate matters
difficulties, leading to an increased capacity can be discussed; being open minded for
to take rational control over feelings and discussion rather than opposing it.
actions, ™™ Conveying Willingness to help.
™™ To modify maladjusted behavior,
Effective Communication Pattern
™™ To assist patients to move in the direction
of fulfilling their potential, or achieve an ™™ Encourage the individual to talk
integration of conflicting elements within ™™ Give hope but do not give undue optimism.
themselves, and ™™ Listen to all facts
™™ To provide patients with the skills,
™™ Create an atmosphere where patient feels
awareness and knowledge, which will accepted and understood
enable them to confront social inadequacy. ™™ Guard against value and moral judgement.
In family practice, the counseling process is Qualities of a Good Counselor
based on the therapeutic effect of the doctor ™™ A good listener
and relies on effective communication skills. ™™ Emphathetic

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 138  Section 4: The Practice of Family Medicine
™™ Non-judgmental
™™ Emotionally mature
™™ Able to maintain confidentiality—able to
discuss sensitive topics
™™ Flexible.
Errors of Counseling
™™ Giving advice.
™™ Offering solution without listening or
analyzing the problem.
™™ Moralizing—preaching good behavior.
™™ Making a person dependent, so that the
person can not take own decision or action.
™™ Blocking emotions; not allowing the
person to express feelings and emotions.
™™ Imposing ones values or judgement.
™™ Interrogating—questioning like a lawyer,
policeman.
Family Physician as an Effective
Counselor18
Family physicians can be effective counselors
for the following reasons:
™™ They have an intimate knowledge of the
family and the family dynamics.
™™ Their generalist skills and holistic approach
permit them to have a broad grasp of the
patient’s problems.
™™ They are skilled at working as a member of
a professional team and solicit their advice
when necessary.
™™ They can provide continuing patient care
with appropriate follow-up treatment
programs.
™™ They can provide treatment/counseling in
comfortable and familiar surroundings—at
their office or patient’s home.
™™ The patients have the advantage of
economy of time and effort.
Specific Areas of Counseling
There are a number of distinct situations in family
practice requiring basic counseling. Complex
problems require a referral, but the family
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physician has a responsibility in the continuing
management and follow-up of such cases. Areas
requiring special counseling include:
™™ Any crisis situation, e.g. epidemic or pandemic
illness such as influenza-like illness.
™™ Bereavement and grief.
™™ Terminal illness or palliative care, e.g.
malignancy, AIDS.
™™ Marital problems, e.g. separation, divorce,
infidelity.
™™ Chronic pain, e.g. cancer pain, neuropathic
pain.
™™ Sexual dysfunction, e.g. low sexual desire,
sexual pain disorders.
™™ Domestic violence, e.g. battering, physical
aggression, humiliation.
™™ Sexual abuse/child abuse/elder abuse.
Individual Counseling
Individuals require counseling because they
are experiencing emotional difficulties such as
depression, anxiety, addiction, grief, traumas,
low self-esteem, guilt, interpersonal problems,
stress reactions and problems in living. The
bottom line is that they are inflicted internally
and are in emotional pain. The aim of the
counsellor in working with individuals is to
enable them to find ways of living that reflect
their needs and values. The counsellor uses
the interview for “therapeutic” purposes.
When, through the interview, the individual
is permitted to think aloud in the presence of
a sympathetic listener, it can give a clue to a
number of problems of the individual.
Family Counseling
The areas which a family needs counseling are
usually mental problems, any crisis situation,
bereavement and grief, terminal illness,
infertility, handicap in a child, domestic
violence, any disease or illness of chronic
nature.
Family counseling is concerned with the
family system and changes that can be made in

that system. If the interaction of the family with
one of its individual members leads to stress, it
is a symptom of a sick system. The symptom,
if allowed to persist, may not only cause much
misery to the individual but also to the rest
of the members of the family. Therefore, the
goal of family counseling is not merely to
remove some symptoms but to create a new
way of living. This involves helping individuals
express emotions, hopes and aspirations. The
family change in facilitated by the counsellor
by striking a balance within the family and by
advising the individuals on how to relate to one
another in new ways.
Although, family physicians are an
important source for health education and have
unique opportunities to influence and modify
health-risk behaviors of their patients, many
surveys have concluded that multiple barriers
such as lack of time and compensation and, to
a lesser extent, lack of knowledge and resources
prevent family physicians from providing
counseling.19-21 Besides, many patient-related
barriers such as patient’s refusal for follow-
up, non-compliance with medications, and
lack of effective patient reminding system
prevent to provide effective counseling.22 Since
family physicians are not trained in the art of
counseling, and to promote greater patient-
physician involvement in counseling, it is
helpful to learn its basic strategies.
Counseling Procedure
Preparation : Before the interview, the
physician needs to work out the entire
interview procedure—how to initiate the
dialogue, what responses can be expected,
how to eliminate unwanted responses and
achieve definite objectives. It is advantageous
to get acquainted with the patient’s earlier
health records, which will give a good start to
the interview and in establishing the rapport.
Make appointment: When appointments are
made, both the patient and the physician are
prepared. It saves time.
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Chapter 16: Counseling Skills 139
Provide for privacy: Privacy is an essential
condition of counseling. It is necessary that the
patient be in a proper frame of mind induced
by privacy.
Practice taking patient’s point of view: The
physician must be able to see the patient’s
point of view, how he/she looks at the problem,
how he/she reacts to counseling.
Know your own personality: The physician
needs to be objective, must be able to
introspect, overcome or at least control
personal opinions, convictions, attitudes,
preconceptions, prejudices and notions.
The Approach
Establish rapport: Establishing relationship
of confidence, trust and mutual appreciation
helps the patient express views without
inhibitions and resistance. The atmosphere of
the physician’s room, attitude and the initial
reception given to the patient helps in this
process.
Help the patient feel at ease and ready to talk:
Counseling should begin with topics, which
are easy to talk about and thus warm up the
patient. After getting to the main topic, the
physician should make the patient talk freely.
Listen: Effective listening is more than passive
taking in information; it is actively focusing
attention on the discussion, events and
experiences, including patient’s feelings
and distress. Physicians should develop
empathy (understanding and acceptance)
for a patient’s feelings, not sympathy (sorrow
and pity). The emphasis here is more on the
communication skills of facilitation, silence,
clarification, paraphrasing and summary,
than on questioning. In many cases this phase
of the counseling constitutes the major part
of the therapy; e.g. in grief or bereavement
counseling, where the doctor supports the
patient through a natural but distressing
process.
 140  Section 4: The Practice of Family Medicine
Secrecy: Physicians will be told many personal
and embarrassing problems of patients. This
information must be kept secret from all other
people, even from patient’s relatives. The
information is never revealed without specific
permission.
Closing: At the close of the interview, watch for
additional information or new leads in the casual
remarks of the patient. The doctor should be
alert to note the patient’s change of expressions,
which may be more relaxed after the interview
has ended and the tension has been released.
The patient may say things, which would have
been expressed earlier (i.e. hidden agenda),
but which seemed irrelevant or too trivial to
mention. The doctor must always remember that
the interview has not yet closed even when the
patient has asked all his questions.
Interpretation: What the patient says is often
a mixture of facts—the views as seen and
felt by the patient. The patient may remain
on a superficial level of self-understanding.
The doctor needs to interpret varied aspects
of these facts and their relationship to the
emotional life of the patient with great skill
and understanding.
Developing insights and action plan: The
process of clarifying and gaining insight
naturally leads to its decisions and planning
of its action, and the decision thus reached is
put to action with doctor’s help.
The doctor helps the patient to reach
decision and put them into practice.
Establish a contract for counseling—with
periodic follow-up to evaluate progress.
Recording—there should be an efficient system
of recording and maintaining the notes. The
entire counseling session may even be tape-
recorded.
Counseling Strategies23
The following recommendations have been
found to be useful in changing certain health
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behaviours. Most of them can be incorporated
into existing office practice. Many can be
implemented in brief periods of time during
routine health visits.
Explore Patients’ Beliefs and Concerns
To persuade patients to change their behavior,
it is first necessary to identify their beliefs
relevant to the behavior and to provide
information based on this foundation.
The physician can elicit important beliefs
by asking such questions as “what gets in your
way of eating a low fat diet? Why do you think
you can’t follow exercise programme?” Once
the patients’ concerns and understanding on
the issues are apparent, teaching can then be
focused appropriately.
Inform Probable Time Duration and
Outcome
Telling the patient when to expect to see
beneficial effects from the intervention may
avoid discouragement. For example, informing
patients that the beneficial effects of low-
fat diet or regular exercise may not become
apparent for several months might increase
the likelihood of long-term compliance. If side
effects are common, the patient should be told
what to expect, and under what circumstances
the intervention should be stopped or the
patient consulted.
Piecemeal Approach
Patients can be advised to do slightly more
than their present effort. When someone is
overweight, losing 100 pounds might seem
like an impossible task. Whereas losing
3 to 4 pounds in the next month seems
reachable. Successful persuasion involves
not only increasing patient’s faith in his
or her capabilities but also encouraging
accomplishments so that they are likely to
experience success.

Be Specific
Specific and informational instructions will
generally lead to better compliance, e.g.
advising the patient to do physical activity
three times a week, and then add to it10 to 25%
more per week until the patient is performing
aerobic exercise 20 to30 minutes for 3 to 4
times a week. Behavior change is enhanced
if the regimen and its rationale are explained.
Add New Behavior
If the patient is unable to follow dietary advice
or cannot change it for some inherent reason
in order to loose weight, then suggesting
moderate physical activity or like any suitable
indoor games may be more effective.
The Use of Combination of Strategies
Educational efforts that integrate individual
counseling, family group, audio visual aids,
written materials and other community
resources are more likely to be effective than
those employing a single technique. Multiple
studies have demonstrated that physician’s
individual attention and feedback are more
useful than the unscientific and hollow
news media’s success reports in changing
individual’s knowledge and behavior.
Involve Office Staff
A team approach facilitates patient education.
Physicians, receptionist, nurses, health
educators, dietitians and the allied health
professionals can form a ‘patient education
committee’, which can help to generate
program ideas and staff commitment.
Get Explicit Commitment
Asking patients to describe how the intended
program will be followed encourages them to
begin to think about how to integrate this new
behavior into their daily schedule. Physicians
should ask patients to describe what, when
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Chapter 16: Counseling Skills 141
and how they plan to achieve a specific target
this week. If the patient expresses uncertainty,
the physician should explore the problems for
the uncertainty. The physician and patient can
then seek situations for potential problems.
Follow-up
Follow-up appointment or telephone call
within a reasonable time frame to evaluate
progress and reinforce success.
Refer
In a busy practice, it may not be possible to do
complete patient education and counseling.
Besides, some patients are refractory to
routine counseling. They must be referred for
specialist services.
Conclusion
The physicians and public health community
are faced with substantial morbidity and
mortality from chronic NCDs that are related
to personal behaviors. With a large and
growing body of literature demonstrating its
effectiveness in promoting healthier behavior,
patient education and counseling has become
an increasingly important part of the delivery
of clinical preventive services.
References
1. B o u t a y e b A . T h e d o u b l e b u r d e n o f
communicable and non-communicable
diseases in developing countries.Trans R Soc
Trop Med Hyg. 2006;100(3):191–9. Epub 2005
Nov 4. [PMID: 16274715: Abstract}.
2. Bahler C, et al. Lower age at first myocardial
infarction in female compared to male
smokers. Eur J Cardiovasc Prev Rehabil,
2011. [Epub ahead of print][PMID: 21930718:
Abstract].
3. Weiner P, et al. Smoking and first acute
myocardial infarction: age, mortality and
smoking cessation rate. Ist Med Assoc J. 2000
Jun; 2(6):446-9. [PMID: 10897236: Free Article].
 142  Section 4: The Practice of Family Medicine
4. Kounteya Sinha. Cancer, diabetes, hypertension
largest cause of death. In: Times of India, 2011.
5. Beaglehole R, et al. Priority actions for the non-
communicable disease crisis. Lancet. 2011;
377(9775):1438–47. Epub 2011 Apr 5. [PMID:
21474174; Abstract].
6. Hickman LD, et al. Can principles of the
Chronic Care Model be used to improve care
of the older person in the acute care sector?
Collegian. 2010;17(2):63–9. [PMID: 20738058:
Abstract].
7. Battersby M, et al. Twelve evidence-based
principles for implementing self-management
support in primary care. Jt Comm J Qual Patient
Saf. 2010;36(12):561–70. [PMID: 21222358:
Abstract].
8. Handley M, et al. Using action plans to help
primary care patients adopt healthy behaviors:
a descriptive study. J Am Board Fam Med. 2006;
19(3):224–31. [PMID: 16672675: Free Article].
9. MacGregor K, et al. Behavior-change action
plans in primary care: a feasibility study
of clinicians. J Am Board Fam Med. 2006;
19(3):215–23. [PMID: 16672674: Free Article].
10. Olson AL, et al. Changing adolescent health
behaviors: the healthy teens counseling
approach. Am J Prev Med, 2008;35(5
Suppl):S359-64. [PMID: 18929982: abstract].
11. Nordin TA, et al. Empirically identified
goals for the management of unexplained
symptoms. Fam Med, 2006;38(7):476–82.
[PMID: 16823672: Free Article].
12. Sinclair J, et al. Which patients receive advice
on diet and exercise? Do certain characteristics
affect whether they receive such advice? Can
Fam Physician, 2008;54(3):404–12. [PMID:
18337535: Free PMC Article].
13. Williams EC, et al. Readiness to change in
primary care patients who screened positive for
alcohol misuse. Ann Fam Med, 2006; 4(3):213–
20. [PMID: 16735522: Free PMC Article].
14. Hardcastle S, et al. A randomised controlled
trial on the effectiveness of a primary health
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care based counselling intervention on
physical activity, diet and CHD risk factors.
Patient Educ Couns, 2008;70(1):31-9. Epub
2007 Nov 7. [PMID: 17997263: Abstract].
15. Richardson JL, et al. Effect of brief safer-
sex counseling by medical providers to
HIV-1 seropositive patients: a multi-clinic
assessment. AIDS, 2004;18(8):1179–86. [PMID:
15166533: Abstract].
16. Wu JY, et al. Effectiveness of telephone
counselling by a pharmacist in reducing
mortality in patients receiving polypharmacy:
randomised controlled trial. BMJ, 2006;
333(7567):522. Epub 2006 Aug 17. [PMID:
16916809: Free PMC Article].
17. David Spiegel et al. Group Support for Patients
with Metastatic Cancer: A Randomized
Prospective Outcome Study. Arch Gen
Psychiatry, 1981;38(5):527–33.
18. John Murtagh. General practice. 1996
Counseling skills: 23.
19. Kushner RF. Barriers to providing nutrition
counseling by physicians: a survey of primary
care practitioners. Prev Med, 1995;24(6):546–
52. [PMID: 8610076: Abstract].
20. Sturm R. Effect of managed care and financing
on practice constraints and career satisfaction
in primary care. J Am Board Fam Pract. 2002;
15(5):367–77. [PMID: 12350059: Free Article].
21. Hansen L, et al. STD and HIV counseling
practices of British Columbia primary care
physicians. AIDS Patient Care STDS, 2005;
19(1):40–8. [PMID: 15665634; Abstract].
22. Hutchison BG, et al. Preventive care and
barriers to effective prevention. How do family
physicians see it? Can Fam Physician. 1996;
42:1693–700. [PMID: 8828872: Free PMC
Article].
23. Guide to Clinical Preventive Services: Report
of the US. Preventive Services Task Force.
2nd edn. US Preventive Services Task Force.
Washington (DC): US Department of Health
and Human Services; 1996.
 17 patient-centered care

“The essence of the practice of medicine is that it is an intensely personal matter. The treatment of a
disease maybe entirely impersonal; the care of the patient must be entirely personal. The significance
of the intimate personal relationship between the physician and patient cannot be too strongly
emphasized—in a large number of cases both the diagnosis and the treatment are dependent on it. One of
the essential qualities of the physician is in his interest in humanity.’’
—John A Benson

Introduction health System for the 21st century,” which

It is a remarkable fact that the science of medicine
is progressing at a breakneck speed. Today the
medical landscape has been transformed
beyond recognition. It is an accepted knowledge
that science has revolutionized medicine by
giving it tools and a scope unimaginable to those
who lived a millennium ago. There have been
impressive technological improvements and
breakthroughs in the medical sciences that have
contributed to enhanced life span and quality of
life. Diseases that were once widespread, and
often fatal, are now easily treatable or have been
virtually eradicated. The drugs are smarter, the
surgical tools more powerful, and the diagnostic
tests astonishingly precise.
However, curing disease is only part of what
makes modern medicine so remarkable; the
other side of its reality is that, while the science
of medicine has leapt forward in mercurial
strides, the art of medicine has not kept pace,
and in many ways has suffered a decline in
quality in an era that values high technology
and cost efficiency over the human aspects
of care. These sordid facts have been further
reinforced by the Institute of Medicine’s project
report titled, “Crossing the quality chasma new
states, “… Medical science and technology
have advanced at an unprecedented rate
during the past half-century. In tandem has
come growing complexity of health care,
which today is characterized by more to
know, more to do, more to manage, more to
watch, and more people involved than ever
before. Faced with such rapid changes, the
nation’s health care delivery system has fallen
far short in its ability to translate knowledge
into practice and to apply new technology
safely and appropriately. And if the system
cannot consistently deliver today’s science and
technology, it is even less prepared to respond
to the extraordinary advances that surely will
emerge during the coming decades.”1
Recent studies show widespread consumer
dissatisfaction with the delivery of health
care. While patients may feel that they receive
excellent technical care, they complain
that the healthcare system is impossible to
navigate; that they receive scarce information
from providers; that patients and families
are not actively involved in discussions
about care options; and that they are not
supported emotionally. Most patients wanted

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 144  Section 4: The Practice of Family Medicine
acknowledgement of harm done and doctors
punished.2-6
Thus, the dissatisfaction in the conventional
treatment of individual’s chronic and multiple
aliments and their exacerbations has generated
an unprecedented drift of healthcare seekers
to “traditional medicine” (TM) that includes
the Complimentary and Alternative Medicine
(CAM)* management of their illnesses. 7-9
The longer life expectancy has brought with
it increased risks of developing chronic,
debilitating diseases such as heart disease,
cancer, diabetes and mental disorders. Women
may use CAM supplements for dysmenorrhea,
premenstrual syndrome, infertility, nausea and
vomiting during pregnancy, and symptoms of
menopause. The World Health Organization
(WHO) estimates that 80% of world’s population
presently uses CAM for some aspects of primary
health care (Table 17.1).10-12 Besides, CAM is
occurring in the context of broader societal
changes, including consumer movement on
healthcare, which have produced a political
climate in which CAM can increasingly challenge
medicine and seek its own power.13 Further,
the WHO has launched its comprehensive
traditional medicine strategy in 2002, designed
to assist countries to develop national policies
on the evaluation and regulation of TM/CAM
practices.14,15
Why Such Broad Use?
While the conventional medical system’s ability
to treat acute health problems such as coronary
Table 17.1  Complementary and alternative medicine
(CAM) can include the following:
•  Acupuncture,
•  Alexander technique,
•  Aromatherapy,
•  Ayurveda (Ayurvedic medicine),
•  Biofeedback,
•  Chiropractic medicine,
•  Diet therapy,
•  Herbalism,
•  Holistic nursing,
•  Homeopathy,
•  Hypnosis,
•  Message therapy,
•  Meditation,
•  Naturopathy,
•  Nutritional therapy,
•  Osteopathic manipulative therapy (OMT),
•  Qi gong (internal and external Qigong),
•  Reflexology,
•  Reiki,
•  Spiritual healing,
•  Tai Chi,
•  Traditional Chinese Medicine (TCM), and
•  Yoga.
Source: Complementary and Alternative Medicine (CAM);
web site—http://www.medicinenet.com/alternative_
medicine/article.htm. Accessed on-24-10-2010.
events and trauma has dramatically improved,
chronic conditions require innovative and
fundamentally different approach. Unlike
treatment for acute illnesses, which often
respond to one or two focused interventions,
optimal care for chronic diseases demand
that patients pay meticulous attention to
their day-to-day diet, physical activity, self-
management and medication use. To equip
patients with the knowledge and skills required
to care for chronic aliments, physicians need to

*“Traditional medicine” is the sum total of the knowledge, skills, and practices based on the theories,
beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the
maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and
mental illness (WHO). The terms "complementary medicine" and "alternative medicine" are sometimes
used to mean the same thing, but they have different implications. Complementary medicine refers to
therapies used in combination with conventional medicine, while alternative medicine is used in place
of conventional medicine. An example of complementary medicine is using hypnotherapy (hypnosis)
with pain medications to reduce anxiety and enhance relaxation in people recovering from severe burns.
An example of alternative medicine would be following a special diet and taking herbs or vitamins rather
than medications to treat attention-deficit hyperactivity disorder (ADHD).

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provide an extensive amount of education and
support.16,17 When patients are systematically
provided with information and skills to reduce
health risks, they are more likely to reduce
substance use, stop using tobacco products,
practice safe sex, eat healthy foods, and engage
in physical activity.
However, the limited time given for office
appointments makes providing comprehensive
care a challenge. 18,19 During the course of
the treatment, the patient must be content
with fleeting consultations with physicians
who are polite but distant, as they are
invariably overloaded with work. Additionally,
in an increasingly technological medical
environment, the importance of time honoured
doctor-patient relationship can easily be
overshadowed by the latest drugs and therapies.
Parallel to the advancement of medical
science, physicians have become more and
more mechanical and stereotype in treating
patients. As physicians depend increasingly on
sophisticated diagnostic tests and specialized
knowledge, patients tend to loose their identity
as human beings. The high-tech speciality care
is indifferent to patients’ values and concerns.
For example, if a person has an infection,
a conventional physician may prescribe
an antibiotic to kill the invading bacteria.
CAM practitioners, on the other hand, take
a more “holistic” approach to health care.
They believe that health and disease involve
a complex interaction of physical, spiritual,
mental, emotional, genetic, environmental,
and social factors. In order to treat a disease or
promote good health, CAM practitioners treat
the whole person (Table 17.2).
It’s the absence of patient-centered care
and warmth that is sorely missed in the present
day procedures while administering healthcare
to the needy. The conventional scientific
medicine has lost the art of treating patients as
*Padmashri Dr R Marthanda Varma, the Founder-Director of the National Institute of Mental Health and
Neurosciences (NIMHANS), Bengaluru, passed away in Bengaluru on March 10, 2015, at the age of 93.
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Chapter 17: Patient-centered Care 145
Table 17.2  Basic principles of CAM
•  T he focus is on the whole person -physical,
emotional, social, and spiritual.
•  Prevention of illness is a primary concern
•  Treatments are highly individualized.
•  Treatments are aimed at the causes of illness
rather than at its symptoms.
•  Treatments are designed to support the natural
healing processes of the body.
individuals, consisting of body, mind, and spirit.
As Padmashri Dr R Martanda Varma*, Founder
Director and Prof. Emeritus, Nimhans, India,
has aptly said, “Human achievement is high but
humanness is lagging behind. We must adopt
an integrated approach. The integrated holistic
approach is “twice blessed”. It blesses the healer
as well as the healed.”20
Defining Patient-centered Care
Fortunately, in the last couple of decades it
has been felt that patients need to be treated
as a whole. Patient-centered care has attracted
leaders in visionary healthcare organizations,
research institutions and public policy centers
who advocate that patients’ interests and
concerns should be at the center of their own
healthcare experience.21-24
In many patients with physical illness,
psychological factors are important—even
crucial. In others, social factors are vital. In yet
others, there are spiritual factors, such as a sense
of guilt or fear of death. Emotions, personality,
life style, behavior, etc. play a very important role
in causing diseases and hence there is a need to
take care of these factors as well in the long-term
management of such patients.
As against the “disease-centered”
consultation—the attitude derived from
undergraduate teaching in which history,
physical examination, and investigations
are taught to “hone in” on a specific area of
physical or pathophysiological diagnosis
 146  Section 4: The Practice of Family Medicine
that is attempted to correct, the “patient-
centered” consultation emphasizes the
need to look at the whole person, including
analysis of physical, nutritional, emotional,
environmental, social, spiritual and life style
values. It includes all stated modalities of
diagnosis and treatment, including drugs
and surgery, if no safe alternative exists. The
physician also focuses on education and
responsibility for individual’s efforts to achieve
balance and well-being (Table 17.3).
Patient-centered care represents a departure
from the historically passive role of our patients
Table 17.3  Whole individual approach: Diagnosis and
management25
Disease-centered Patient-centered
Diagnosis Diagnosis
• Etiology of • Significance of illness to the
disease patient
• Effect of family and relationship
• Effect on work and income
•  Physiological effect:
–  Stress and anxiety
– Abnormal illness and
behavior
–  Sleep
–  Depression
•  Effects on sexuality
•  Effects on attitudes and
spirituality
Disease-centered Patient-centered management
management •  Psychological support
•  Rest •  Appropriate reassurance
•  Drugs •  Patient education
•  Intervention • Empowering self-
•  Surgery responsibility
•  Other invasive •  Anticipatory guidance
techniques •  Prevention
•  Health promotion
•  Lifestyle
Recommendations/
modifications
–  Diet/nutrition
–  Exercise
– Alcohol
–  Smoking
–  Stress management
•  Family and social support
•  Self-health groups
•  Alternative options
•  Consultation and referral
•  Follow-up
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in their care. As patient-centered physicians,
physicians emphasize the patients’ needs
and feelings and attempt to gain a better
understanding of the impact of medical decisions
on our patients’ lives (Table 17.4). Using patient-
centered techniques, physicians move beyond
the pathophysiology of disease and explore the
biological, psychological, and social components
of our patients’ illness. Balient stated, “More
often than scientific medicine cares to admit,
it is not with a part but with a whole man that
something has gone wrong, so that not one part
but the whole man must be examined.”26
Prof. Dr McWhinney IR 27 gives the grounds
for the patient-centered clinical method; his
reasons seem first and foremost based on
philosophical and ethical considerations.
The one-dimensional biomedical paradigm is
insufficient for the comprehension of current
medical knowledge, and more important, it
is based on an inadequate and impoverished
view of reality. A reciprocal bio-psycho-
social paradigm is advocated, where the
understanding of the patient’s perspectives
and subjective meaning of health problems is
a basic task for the clinician.
In 2001, the Institute of Medicine
described patient-centered care as, “being
respectful of and responsive to individual
patients’ preferences, needs, and values and
ensuring that patient values guide all clinical
decisions.”28 The physician’s role, then, is to
help patients find goals that are more relevant
to them and then use those goals to develop
the patient-specific plans.
Thus, patient-centered care will reflect
patients’ values and engage them as partners
Table 17.4  Patient-centered clinical method:
Components of patient-centered care
•  Exploring the disease and the illness experience.
•  Understanding the whole person.
•  Finding common ground regarding management.
•  Incorporating prevention and health promotion.
•  Enhancing the doctor-patient relationship.
•  Being realistic.

in their care. Patients and their families must
be involved in decision-making. They need
education, information, and coaching to
facilitate their informed and full participation.
Seven Prime Aspects of Patient-
centered Care 29
1. Safe—avoiding injuries to patients from the
care intended to help them.
2. Effective—providing services based on
scientific knowledge to all who could
benefit, and refraining from providing
services to those not likely to benefit.
3. Patient-centered—providing care that is
respectful of and responsive to individual
patient preferences, needs and values,
ensuring that patient values guide all
clinical decisions.
4. Timely—reducing waits and harmful delays
for both those who receive and those who
give care.
5. Efficient—avoiding waste: including waste
of equipment, supplies, ideas, and energy.
6. Equitable—providing care that does not vary
in quality because of personal characteristics
such as gender, ethnicity, geographic
location, and socioeconomic status.
7. Transition and continuity—Delivery
systems provide for caring and sharing
ongoing care between different providers
and phases of care.
Evidence Base for Patient-
centered Care (PCC)
There is considerable evidence that patients
prefer a patient-focused approach.
In a study to measure the use of medical
services and related charges monitored
over 1 year, Bertakis KD et al reported,
“Patient-centered care may result in greater
knowledge of the patient, greater trust between
physician and patient, and diminished need
for additional specialty referrals, diagnostic
testing, and use of hospital care.”30
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Chapter 17: Patient-centered Care 147
In a study conducted by Ratanawongsa N
et al to improve residents’ competencies in
delivering patient-centered care, it was found
that, “A patient-centered inpatient curriculum
was associated with higher satisfaction ratings
in patient-centered domains by internal
medicine residents and with higher satisfaction
ratings of their physicians by patients.”31
In a study of women with breast cancer,
Mellinger J.B. et al state that, “patient satisfaction
is improved when physicians incorporate
patient-centered behaviors into their care.” 32
There is also a growing body of evidence
supporting other key dimensions for PCC such
as respect for patients’ values, preferences, and
expressed needs; coordination and integration
of care; information, communication, and
education; physical comfort ; emotional
support; involvement of family and friends;
transition and continuity of care; and access
to care
There is also good evidence for PCC having
favorable impact on chronic diseases such as
diabetes, asthma, hypertension, and musculo-
skeletal conditions, especially if a team
approach to the management is developed.33
Patient’s Choice
Little et al 34 conducted research to seek
answers to crucial questions about patient
centered medicine. What is it? Do patients
want it? Their results indicate that the answer
to these questions is a resounding “yes.”
Patients want PCC which:
™™ Explores the patients’ main reason for the
visit, concerns, and need for information;
™™ Seeks an integrated understanding of the
patients’ world that is, their whole person,
emotional needs, and life issues;
™™ Finds common ground on what the
problem is and mutually agrees on
management;
™™ Enhances prevention and health pro­
motion; and
 148  Section 4: The Practice of Family Medicine
™™ Enhances the continuing relationship
between the patient and the doctor.
Patient-centeredness—What
Determines the Physician’s
Clinical Behavior?
A study of primary care physicians in
Singapore, consisting of ninety GPs in a cluster
of nine polyclinics, using case scenarios and
patient-centered statements through a self-
administered questionnaire was carried out.
The object of the study was to assess patient-
centered care behavior amongst physicians
and explore reasons for non-patient centered
behavior.35
The analysis of the results for non-
patient centeredness revealed that the major
contributory factor was doctor-centered
attitudes, followed by time and skill issues,
which appeared to be situation-specific.
Wi t h i n d o c t o r- c e n t e re d i s s u e s,
negative regard for the patient, inflexible
professionalism, concern about policy
matters of health system, protecting one’s
own legal interest, and diminished personal
accountability were important issues.
Within skill-centered issues, communi­
cation skills, negotiation skills and professional
inadequacy predominated. Time allocation
was a limiting factor to provide health
promotion guidelines.
The study concludes to state, “Can we
postulate that these attitudes are part of the
professional ego that has been acquired during
the course of medical training? If so, have our
senior colleagues been less than ideal role
models in teaching patient centeredness?
There is probably a need for more training
on PCC at all levels of seniority from medical
students to professors. There is also a need
to recognize current structural limitations
on doctor’s practice, e.g. time constraints,
patient’s autonomy and disillusions. Steps
should be taken to overcome these.”
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Patient-center Care Model
The model of patient-center care described by
Brown et al36 consists of six essential interactive
components:
1. Exploring both the disease and the illness
experience:
Disease: The traditional approach of
history taking, physical examination to
arrive at a differential diagnosis.
Illness: At the same time, the physician
tries to evaluate patient’s ideas, feelings,
and fears concerning the illness and its
effect on his activities. Knowledge of past
illness experiences and the effect of the
family on previous illness can be useful to
access the severity of disease the patient is
going through.
The physician usually maneuvers back and
forth between the “doctor disease” and the
“patient illness” agendas.
2. Understanding the whole person:
Physicians need to approach patients not
as “cases” or “diseases” but as individuals
whose problems all too often transcend the
complaints that bring them to the doctor.
Whatever patients complaints, including
their attitude and beliefs toward their
illness, the physician needs to consider the
settings in which an illness occurs, in terms
of not only the patients themselves, but also
of their families and social backgrounds.
Patient’s life in terms of development,
previous contacts with the patient over the
years can provide the physician valuable
insights into the present problems.
3. Finding common grounds (i.e. concordance):
The physician must ensure coordinating
personal views of what should be done with
that of patient’s.
Understanding the nature of patient’s
problems, setting priorities and goals of
treatment, mutual responsibilities and
cooperation are essential for effective
management.

Finding common ground rather than
bargaining or negotiating requires an
understanding of the patient’s ideas, fears,
and expectations regarding the problems.
4. Incorporating prevention and health
promotion:
The physician is in a favorable position to
provide patients with specific information
a b o u t h e a l t h p ro m o t i o n , d i s e a s e
prevention and risk reduction at every
contact with patients and these families.
This continuous process facilitates effective
patient-centered relationship. This paves a
smooth way for the patient’s acceptance
of suggestions from the physician for
appropriate life style modifications.
5. Enhancing the doctor-patient relationship:
The physician makes full and intelligent
use of the opportunity of the intimate
doctor-patient relationship. In patient-
centered care this relationship is not static;
it develops in the light of patients’ needs,
but it is grounded in the timeless clinical
virtues of trust and confidence.
6. Being realistic:
Treating the whole person with caring
and compassion and attending to the
preferences and needs of patient means
understanding what is important to the
patient. This requires priority setting,
resource management, and teamwork.
The physician needs to plan carefully
the time and the resources to meet these
tasks without being overburdened, overly
distressed, or emotionally depleted.
Physician needs to work as a part of a
community team across disciplines for
optimum PCC.
Hypothetical Case Scenario: An
Adult Diabetic37
Presentation
A 50-year-old lady, Ms X, working as a
secretary, presents for a repeat prescription
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Chapter 17: Patient-centered Care 149
of antihypertensive medications. She is
overweight, does not smoke or drink; her BP is
170/96 mm Hg; spot glucometer blood glucose
shows 240 mg/dL. She is on ACE inhibitor and
statin. When questioned further about her
present illness history, she informs that her
neighboring physician recently told her, she has
mild diabetes not requiring active treatment.
Management: Disease-centered
Physician: you may have diabetes. You also
have a number of risk factors. Combined with
your hypertension this makes your risk very
great for vascular events. You must loose at
least 10 kg weight. Get plenty of exercise and
avoid sweets. I will order tests (diabetic and
lipid profile) and adjust medications.
Ms X: Yes, of course, you are a doctor, so tell
me what to do.
Physician: It is really important that you control
your blood glucose levels; the consequences
could be otherwise serious.
Two years later: Ms X has given up job; she is
confined to her home with a foot ulcer; her BP
remains unstable, and she has angina.
Management: Patient-centered
Physician: Both blood glucose and blood
pressure is high today. Have you been regularly
taking pressure tabs?
Ms X: Not exactly doc… my husband is also
on medications, and I got to buy them as
well… I have no adequate mediclaim cover
to reimburse these expensive drugs. So I am
on occasions hard for cash to buy all drugs…
nothing seems to happen if I miss a few
pressure pills…so I thought I would get them
after my next pay.
Physician: Both diabetes and high blood
pressure are silent diseases. Missing doses
cause complications without hurting. If you
can’t afford drugs, I can help getting them
 150  Section 4: The Practice of Family Medicine
from specific pharma companies who will
mail you necessary drugs at no cost on my
recommendation. Now please tell me about
your diet.
Ms X: Thank you doc…about my diet, I try to
follow, but we have frequent guests and I have
to eat with them when they visit.
Physician: Your spot blood glucose is high. We
need to monitor it regularly. It is important that
we learn more about your diabetes and help
you look after it. Let’s make an appointment
for you with our dietician at the local Diabetic
Center this week. She will help you work out
balanced diet to reduce weight as well as
proper blood glucose control.
Ms X: I understand I must loose weight. Do I
have to follow rigid dieting?
Physician: Perhaps we should set a small
target for weight loses for the first 2 months
or so. Diet is important, but rigid dieting is
not advisable. Adding a bit more of physical
activity is very helpful to reduce weight. Can
you keep a list of all your daily activities? Please
go through this information booklet; it explains
how to maintain your chart for daily physical
activities—it’s simple to follow and maintain.
Ms X: I will try to follow…I understand its
importance.
Physician: Let’s talk about it more next week.
I will call you to know about your progress. I
will also enroll you as a member of the Diabetic
Organization; you will receive useful support
services from them.
A fortnight later: Ms X receives a letter from the
Diabetic Organization.
The letter adds: “Please be assured you are
not just another ‘diabetic case’. You are an
individual, with needs of body, mind and spirit,
and you live in a home perhaps beset with many
problems. Please be free to talk to our expert
educational team; they will soon visit you with
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an appointment. We hope you will be better
equipped to deal with life, with all its demands
and perplexities.”
Two years later: Ms X has lost 5 kg weight; she
is active for half an hour on most days with the
local walking group; she remains at work; her BP
is mostly under 140/90 mm Hg and HbA1c 7.5%.
Teaching Points
™™ Patient’s beliefs about disease are considered.
™™ Poor adherence may be due to physical or
socioeconomic reasons; each needs to be
explored.
™™ Lifestyle modifications in terms of diet and
exercise are stressed.
™™ Key behavioral strategies include a written
plan for behavioral change, reinforcement,
and follow-up.
™™ Support links to ease financial burden is
offered.
™™ Community links to diabetic organization
established.
™™ Outcome—improved quality of life.
Conclusion
Patient-centered care is an important and
evidence-based concept for improving health
outcomes for people with chronic disease in
primary-care practice.
The Institute of Medicine report states there
is a “quality chasm” in our healthcare system
today, and this certainly applies to the spectrum
of chronic disease management. The tension
between the need to deliver comprehensive
care and the time allotted to do so can be met
effectively only by changing the way we manage
our visits: by conducting patient-centered,
goal-focused care; working collaboratively
with formal patient education programs; and
continually looking for ways to educate and
motivate patients to better care for themselves.
Systematic reviews show that patient-
centered care results in increased adherence

to management protocols reduced morbidity
and improved quality of life for patients.
To deliver the highest quality care means
to address all of patients’ health related needs,
concerns, and interests. A broad, comprehensive
education in medicine, including CAM, must be
fashioned to meet the needs of a diverse and
changing population of patients.
References
1. Crossing the Quality Chasm: A New Health
System for the 21st Century. Institute of
Medicine, March 2001.
2. Wong LL, et al. Patients’ complaints in a
hospital emergency department in Singapore.
Singapore Med J. 2007;48(11):990–5. [PMID:
17975687: Free Article].
3. Lim HC, et al. Why do patients complain? A
primary health care study. Singapore Med J.
1998;39(9):390–5.[PMID: 9885716].
4. Taylor DM, et al. Analysis of complaints lodged
by patients attending Victorian hospitals, 1997-
2001. Med J Aust. 2004;181(1):31–5. [PMID:
15233610: Free Article].
5. Daniel AE, et al. Patients’ complaints about
medical practice. Med J Aust. 1999; 170(12):598–
602. [PMID: 10416431:Free Article].
6. McKinstry B, et al. Can doctors predict
patients’ satisfaction and enablement? A
cross-sectional observational study. Fam Pract.
2006;23(2):240–5. Epub 2006 Feb 3. [PMID:
16461447:Free Article].
7. Astin JA, et al. A review of the incorporation
of complementary and alternative medicine
by mainstream physicians. Arch Intern Med.
1998;158(21):2303–10. [PMID: 9827781: Free
Article].
8. Fink S. International efforts spotlight traditional,
complementary, and alternative medicine. Am
J Public Health. 2002;92(11):1734–9. [PMID:
12406796: Free Article].
9. Vohra S, et al. Ethics of complementary and
alternative medicine use in children. Pediatr
Clin North Am. 2007;54(6):875–84; x. Review.
[PMID: 18061781: Abstract].
10. Ozorio P. World Health Organization encourages
traditional medicine in the third world. Dev Dir.
1979;2(4):16. [PMID: 12309965: abstract].
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Chapter 17: Patient-centered Care 151
11. Akerele O. Nature’s medicinal bounty: don’t
throw it away. World Health Forum. 1993;
14(4):390–5. [PMID: 8185790: Abstract].
12. Bodeker G, et al. A public health agenda for
traditional, complementary, and alternative
medicine. Am J Public Health. 2002;92(10):
1582–91. [PMID: 12356597: Free Article].
13. Coulter Ian D, et al. The rise and rise of
complementary and alternative medicine: a
sociological perspective. Med J Aust. 2004;180:
58–89.
14. WHO launches the first global strategy on
traditional and alternative medicine. Cent Eur
J Public Health. 2002;10(4):145, 156. [PMID:
12528386].
15. WHO Policy Perspectives on Medicines—
Traditional Medicine—Growing Needs and
Potential, No. 2 May 2002, World Health
Organization, Geneva.
16. Rao JK, et al. Visit-specific expectations and
patient-centered outcomes: a literature review.
Arch Fam Med. 2000;9(10):1148–55. [PMID:
11115222: Free Article].
17. Kravitz RL, et al. Internal medicine patients’
expectations for care during office visits. J Gen
Intern Med. 1994;9(2):75–81. [PMID: 8164081:
Abstract].
18. Lin CT, et al. Is patients’ perception of time
spent with the physician a determinant of
ambulatory patient satisfaction? Arch Intern
Med. 2001;161(11):1437–42.PMID:11386893:
Free Article].
19. Landau DA, et al. Patients’ views on optimal
visit length in primary care. J Med Pract
Manage. 2007;23(1):12–5.[PMID:17824257 :
Abstract].
20. Padmashri Dr. R Martanda Varma. Founder
Director and Prof. Emeritus, NIMHANS,
Bangalore, India; Deccan Herald, 2002.
21. Committee on Hospital Care. American
Academy of Pediatrics. Family-centered care
and the pediatrician’s role. Pediatrics, 2003;112
(3 Pt 1):691–7. [PMID: 12949306: Free Article].
22. Zimmerman J, et al. Collaborative models of
patient care:new opportunities for hospital
social workers. Soc Work Health Care. 2007;
44(4):33–47. [PMID: 17804340: abstract].
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23. Ekman I, et al. Person-centered care - Ready
for prime time. Eur J Cardiovasc Nurs. 2011;
10(4):248–51. Epub 2011 Jul 20. [PMID:
21764386: Abstract].
24. Maizes V, et al. Integrative medicine and
patient-centered care. Explore (NY). 2009;
5(5):277–89. [PMID: 19733814: Abstract].
25. Murtagh John. General Practice: whole person
approach to management, 1996:72.
26. Balient M et al. Treatment or diagnosis: A study
of repeat prescriptions in general practice,
Tavistock Publications Ltd. London, 1970.
27. McWhinney IR. Philosophical and scientific
foundations of family medicine. In: A Text Book
of Family Medicine. New York, Oxford: Oxford
University Press. 1989:43–71.
28. Committee on Quality of Health Care in
America, Institute of Medicine. Crossing the
Quality Chasm: A New Health System for
the 21st Century. Washington, DC: National
Academies Pr; 2001.
29. The Picker Institute. Patient-Centered Care 2015:
Scenarios, Vision, Goals & Next Steps. July 2004.
30. Bertakis KD, et al. Patient-centered care
is associated with decreased health care
utilization. J Am Board Fam Med. 2011;
24(3):229–39. [PMID: 21551394: Free Article].
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31. Ratanawongsa N, et al. Effects of a Focused
Patient-Centered Care Curriculum on the
Experiences of Internal Medicine Residents
and their Patients. J Gen Intern Med. 2011.
[Epub ahead of print][PMID: 21948228:
Abstract].
32. Mallinger JB. et al. Patient-centered care
and breast cancer survivors’ satisfaction
with information, Patient Education and
Counseling. 2005;57(3):342–49.
33. Coates Heather. Integrating patient-centered
care and evidence-based practices: What is
the prognosis for healthcare? School of Library
and Information Science, Indiana University -
Indianapolis, S653: Research Paper. 2007.
34. Little P et al. Preferences of patients for patient
centered approach to consultation in primary
care: observational study. BMJ. 2001;322:468–72.
35. Yvette Sh Tan et al. Patient centeredness: What
determines the doctor’s clinical behavior. Oral
presentation at WONCA Europe, Slovenia. 2003.
36. Brown JB, et al. Patient centered medicine:
transforming the clinical method. Saga
publications. 1995.
37. Bauman AE et al. Getting it right: why bother
with patient centered care? Medical J of Aust.
2003;179(5):253–6.
 18 the team approach

“The sum total of medical knowledge is now so great and wide-spreading that it would be futile for any one
man... to assume that he has even a working knowledge of any part of the whole.… The best interest of the
patient is the only interest to be considered, and in order that the sick may have the benefit of advancing
knowledge, union of forces is necessary.… It has become necessary to develop medicine as a cooperative
science; the clinician, the specialist, and the laboratory workers uniting for the good of the patient, each
assisting in elucidation of the problem at hand, and each dependent upon the other for support.”
—William J. Mayo, 1910
“Coming together is a beginning, keeping together is progress, and working together is success.”
—Henry Ford

Introduction participation in team-based efforts. High-

In today’s complex world of modern
medicine, no one professional system is
able to provide the multifaceted care which
families need—from acute care to those
suffering from terminal illness. Besides
planning and implementing health policies
that will enhance patients’ health, including
health promotion, screening, and preventive
care, family physicians shoulder the unique
responsibility of arranging coordination of
care, specialist referrals, hospital, home,
and hospice visits to provide continuing and
comprehensive care. Family physicians also
have an important role in the effective use of
community resources. To optimally manage
the care of the individuals and groups of
patients, physicians must understand how
the healthcare system functions, and how
to effectively use those systems to deliver
safe, timely, effective and patient-centered
healthcare. Managing the care of individuals
and populations often requires physician
quality and effective clinical practice in this
environment requires a physician to be a
member, and often a leader, of many teams
that must work together to deliver health care
(Fig. 18.1).1
Need for Team Concept
Since the patient-centered care has become a
priority in family practice, family physicians
should be aware of the availability and the
role of other professionals, such as specialists,
therapists, dieticians, nurse practitioners,
pharmacists, office staff, social workers, and
many health workers, in the overall care
of patients. The concept is that all these
professional services should be available to
the families according to their needs, and
that services should be cooperative and
coordinated.
Such an approach calls for “team
concept”— a team wherein all concerned
are associated together for the good of the

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 154  Section 4: The Practice of Family Medicine
Fig. 18.1  Team care concept in family healthcare system
patient. Yet, getting individuals with distinct
personalities, experience, likes, and dislikes,
and motivating them to work together
toward a common goal is one of the most
challenging tasks faced by the health resource
organizations. When individuals from different
backgrounds and areas of expertise come
together, conflict often arises and creates
barriers to teamwork and progress.
In order to eliminate the negative impact
of team conflict, and to get team individuals
moving in the right direction, a team
leader is essential, who will take the overall
responsibility, and be answerable if something
goes wrong. In theory any member of the
team can act as leader, but usually the person
who has vast knowledge and experience is
best suited for this role. In the community a
strong argument can be made for the family
physicians to lead the healthcare team
because they form a common link between
the patients and the community. Besides,
family physicians, in the role of a team leader,
are aware of the strengths and weaknesses
of the team members, and are able to utilize
their services to the patient’s advantage.
Such an approach facilitates involvement
of connected teams of health professionals
working together to provide more coordinated
and comprehensive care to patients. It places
priority on the preferences of the patient and
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fosters respect for the skills and perspectives
of all health-care providers.
Personal versus Team Care
There is a very fine line to be treated in
employing teamwork so that it does not
undermine the important concept of “personal
care”. Most patients prefer to be cared for by
one physician who they know and trust, rather
than by a team of physicians who are unknown
to them. As patients do not always appreciate
sharing of responsibility that is an integral part
of the teamwork, it is necessary for the primary
team physician to explain such interventions
when necessary. The team doctor should take
the responsibility for ensuring that:
™™ The team provides care which is safe,
effective and efficient, works effectively to
achieve high standards of care, including
clinical effectiveness and efficiency; and
™™ The whole team understands the need to
provide a polite, responsive and accessible
and effective service, and to treat patient
information as confidential.2
Team Training: Current Status and
Assessment3
Numerous reports during the past 10 years
from national oversight and safety institutes
and agencies have supported the need for

team training in the healthcare environment,
especially as a means to decrease errors and
increase patient safety. Hospital training
p ro g ra m s have b e gu n i mp l e m e nt i ng
interdisciplinary team training around high-
risk scenarios for their trainees and staff.4
Teamwork has become a major focus in
healthcare. In part, this is the result of the
Institute of Medicine (IOM) report entitled,” To
Err Is Human: Building a Safer Health System”,
which details the high rate of preventable
medical errors, many of which are the result
of dysfunctional or non-existent teamwork.
T h e I O M h a s re c o m m e n d e d t h a t
organizations establish interdisciplinary team
training programs that incorporate proven
methods for team management. Teamwork
can be assessed during physician medical
education, board certification, licensure,
and continuing practice. Team members
must possess specific “knowledge, skills,
and attitudes” (i.e. KSAs) and the ability to
exchange information which enable individual
team members to coordinate.
Assessing Physician Teamwork
KSAs might be elicited and assessed across a
physician’s career, starting in medical school
and continuing through licensure and board
certification. Professional bodies should be
responsible for the development of specific
team knowledge and skill competencies
and for promoting specific team attitude
competencies. Tools are available to assess
medical student, resident, and physician
competence in these critical team KSAs.5
Working with Colleagues
When working in a team, physicians should act
as a positive role model and try to motivate and
inspire their colleagues. The major conduct
codes of impotence are:
™™ Physicians should always treat their
colleagues fairly. In accordance with the
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Chapter 18: The Team Approach 155
ethics, they must not discriminate against
colleagues. It is morally unacceptable
for physicians, whatever their personal
impressions may be about a colleague,
to adversely comment on his or her
professional competence to patients or
members of public.
™™ Physicians should not allow the views of
their colleague’s lifestyle, culture, beliefs,
race colour, gender, sexuality or age to
prejudice their relationship with the
concerned colleague.
™™ Physicians must treat their nursing and
ancillary staff with respect and understanding,
and listen and act sympathetically to their
legitimate work or service complaints. They
must perform their services as part of a team,
and help to create a working environment
that is pleasant and harmonious.
™™ Physicians must avoid looking at colleagues
in their areas of practice as competitors or
rivals. It is more useful for physicians to
project the image of a team, with common
practice guidelines so that patients will
appreciate this and avoid clinic hopping.
™™ As multidisciplinary teams are increasingly
providing healthcare, they are expected
to work constructively within teams and
to respect the skills and contributions of
colleagues and other healthcare staff.
™™ Finally, physicians must always remember
that they have attained their medical
education and training through teaching
by their peers. It is therefore an honor and
privilege to them to perpetuate the art and
craft of medical practice by imparting their
knowledge and sharing their experiences
with their colleagues and students at all
times.
The General Medical Council in United
Kingdom has the following guidelines in the
context of “working in team”: 6
Physicians must:
™™ Respect the skills and contributions of your
colleagues.
 156  Section 4: The Practice of Family Medicine
™™ Communicate effectively with colleagues
within and outside the team.
™™ Make sure that your patients and colleagues
understand your role and responsibilities
in the team, and who is responsible for
each aspect of patient care.
™™ Participate in regular reviews and audit of
the standards and performance of the team,
taking steps to remedy any deficiencies.
™™ Support colleagues who have problems
with performance, conduct or health.
Communication Strategies
In academic medical settings, healthcare team
members share the same goal, i.e. to provide
optimal care for the patient and effective
training for house staff and students. However,
communication and teamwork failures are a
common cause of adverse events. Therefore,
instituting a multidisciplinary teamwork
training program that uses simulation offers
a risk-free environment to practice skills,
including communication, role clarification,
and mutual support.7,8 Further, Spanager L, et
al. state that, “Good clinical skills and dexterity
alone do not make a good surgeon. Skills in
leadership, decision-making, communication
and teamwork, the so-called non-technical
skills, are also needed.”9 Therefore, giving
team members the opportunity to improve
their communication skills facilitates their
work together.
The following strategies, outlined by
Rider Elizabeth et al, that have contributed
to the success and lessons learned from
incorporating clinician communication skills
in medical teams can help healthcare team
members communicate more effectively and
resolve conflicts.10, 11
Be Respectful and Professional in
your Interactions
Treat team-mates with dignity, politeness, and
kindness; do not nit-pick or criticize over little
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things; treat colleagues the same, irrespective
of their professional status.
Listen
Listen intently to the other person; do not
interrupt or cut off another person; engage in
active listening; it shows concern and interest.
Try to Understand the Other Person’s
Viewpoint
Ask for clarification; ask probing follow-up
questions which will give your colleague
the opportunity to bring up hidden agenda.
The information you gain will help you to
determine a responsible course of action.
Acknowledge the Other Person’s
Thoughts and Feelings
Using “yes–no” questions may generate more
information to arrive at a suitable solution.
Be Cooperative
Assume good faith with colleagues’ through
friendliness, interest, empathy, and non-
judgemental attitude.
Look for Shared Concerns
Include all team mates in meetings, discussions,
training, and events. Focus attention on the
importance of teamwork and communication in
avoiding unintended harm to patients and errors.
State your Feelings
Share information about yourself and team
performance; use words such as,” In my
opinion…or, I think…or, I feel…” Avoid
judgments and accusations.
Don’t Take Things Personally
There are times when ineffective
communication creates conflict (anger,
frustration) even in situations where there is

no real “conflict issue” or disagreement about a
specific issue and tends to erode relationships.
However, avoid unsolicited advice. If needed,
take a break, or you may say, “I am sorry …I
lost my cool ….can we discuss about this later
after things cool off?”
Learn to Say, “I was Wrong”
Apologizing when it is appropriate can be
particularly effective, especially to keep and
develop a good relationship. There are no
winners or losers. The two of you are on the
same team and need to work together. It is an
act of a true leader when you are able to admit
a wrong or mistake.
Don’t Feel Pressured to Agree Instantly
Try not to solve the problem prematurely.
“Let’s consider the next step and find the time
to meet again.”
Think About Possible Solutions
Before Meeting
What do you really want? What might you give
in order to get it? Is there a compromise you
can live with? Offer and ask for solutions. A
neutral third party may be useful.
Think of Conflict Resolution as a
Helical Process
Handling conflict is not a linear process,
and conflicts are rarely resolved in one
interaction. Rather, participants return to
the spiral, readdress issues at a higher level,
and sometimes regress before reaching a
resolution. Real progress is gradual, being built
patiently, and often step-by-step.
Team Cover on Off-Duty or Leave5
Physicians on off-duty, or before proceeding
on long leave from practice, should give
advance notice to their regular patients,
and whenever possible give alternative
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Chapter 18: The Team Approach 157
appointments if they are on regular follow-up.
Suitable arrangements by another physician or
team mate should be provided when patients
urgently need treatment.
In the case of hospital patients, the physician
going on leave must ensure effective hand
over procedures to a colleague to continue
management. The colleague covering such
patients must agree, and the patient and his
relatives must also be made aware of this
arrangement. Messages left on the pager or
answering machines are considered discourteous.
The physician or team mate standing
in should have, as far as possible, similar
qualifications, experience, knowledge and
skills as the physician proceeding on leave.
This will enable the incoming physician to
perform the duties at par.
Conclusion
A growing body of literature indicates that
medical teamwork improves the quality,
safety, and cost-effectiveness of healthcare
delivery, and expectations for teamwork in
health care have increased. However, success
is highly dependent on organizational factors
such as leadership support, learning climate,
and commitment to data-driven change.12
Within primary care, it has been suggested
that multidisciplinary team working is essential
to develop an integrated approach to promoting
and maintaining the health of the population
whilst improving service effectiveness.
Forming a healthcare team from diverse
groups of individuals with distinct abilities,
experiences, and values is a complex process;
but when such a team works in harmony,
it heralds practice success, professional
fulfillment, and patient satisfaction. As Andrew
Carnegie aptly states,” Teamwork is the ability
to work together toward a common vision; the
ability to direct individual accomplishments
toward organizational objectives. It is the
fuel that allows common people to attain
uncommon results.”
 158  Section 4: The Practice of Family Medicine
References
1. O’Connell MT, et al. Undergraduate Medical
Education for the 21st century: Ledership and
Teamwork. Fam Med, 2004;36(January Suppl.):
S51–S56.
2. General Medical Council, UK. Good Medical
Practice. 2nd edn. 1998.
3. Baker DP, et al. The role of teamwork in the
professional education of physicians: current
status and assessment recommendations. Jt
Comm J Qual Patient Saf, 2005;31(4):185–202.
[PMID: 15913126: Abstract].
4. Morrison G, et al. Team training of medical
students in the 21st century: would Flexner
approve? Acad Med, 2010;85(2):254–9. [PMID:
20107351: Abstract].
5. Niraj L, et al. A Multidisciplinary Teamwork
Training Program: The Triad for Optimal
Patient Safety (TOPS) Experience. J Gen Intern
Med, 2008;23(12):2053–7.
6. Web site : http://www.gmc-uk.org/guidance/
good_medical_practice/working_with_
colleagues_working_in_teams.asp.
mebooksfree.com
7. Deering S, et al. Multidisciplinary teamwork
and communication training. Semin Perinatol,
2011;35(2):89–96. [PMID: 21440817: Abstract]
8. Sehgal NL, et al. A multidisciplinary teamwork
training program: the Triad for Optimal Patient
Safety (TOPS) experience. Gen Intern Med,
2008;23(12):2053–7. Epub 2008 Oct 2. [PMID:
18830769: Abstract].
9. Spanager L, et al. Surgeons also need non-
technical skills. Ugeskr Laeger, 2011;173(6):410–3.
Danish. [PMID: 21299932: Abstract].
10. Rider Elizabeth. Twelve strategies for effective
communication and collaboration in medical
teams. BMJ, 2002;325:S45
11. Rider EA, et al. A model for merging residency
programmes during health care consolidations:
a course for success. Medical Education,
2003;37:794–801.
12. Salas E, et al. What are the critical success
factors for team training in health care? Jt
Comm J Qual Patient Saf, 2009;35(8):398–405.
[PMID: 19719075: Abstract].
 19
“The child: “what can you do for me?” The adolescent: “I want to do it alone.”
The adult: “Let’s do it together;” The leader: “What can I do for you?”
Physicians as Leaders
In today’s modern medicine, family physicians
(FP) are as vital to the community as the
general practitioners (GP) of the eighteenth
and nineteenth centuries—both FPs and
GPs normally being the point of first contact
within the healthcare system for patients, and
they continue to provide the bulk of medical
care even in today’s arduous ambulatory
healthcare system. The time honoured core
competencies, i.e. primary care management,
patient-centerd care, specific problem solving
skills, comprehensive approach, community
orientation, and a holistic approach underpin
the fundamental principles for both GPs and
FPs, regardless of the age, sex, or any other
characteristic of the person concerned.
However, modern medicine, characterized
by the enormous impact of rapid advances in
science and technology, has vastly enhanced the
doctor’s professional capabilities and has made
the practice of medicine more intellectually
challenging.1,2 Unlike the GP of olden days, the
present-day FP plays a more complex role in the
process of ensuing the community’s healthcare
delivery system. In order to succeed, the 21st
century GP/FP must be self-confident and
believe in oneself; must know how to cooperate
with other health care professionals at various
levels—from medical directors, departmental
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Leadership
—Denis Waitley. “Empires of the Mind.”
chairs, professional societies, and residents;
must know how to think in terms of both the
individual patient and the community; must
practice with humane and technical qualities;
must fight against the abuse of technology and
the fragmentation of healthcare; and is expected
to be prestigious, competent and polyvalent.3
In addition to knowing the technical aspects
of medicine, the GP/FP must learn about the
applied aspects of epidemiology, behavioral
science, environmental health, and basic health
economics that are relevant to general/family
practice. The World Health Organization’s
charter for general practice/family medicine
in Europe states, “Although general practice
is an old profession, its profile has been
reshaped during recent decades, and adapted
to emerging needs and new opportunities
following social and technical developments.
Several professional and scientific groups and
organizations have reformulated the status
and aims of general practice/family medicine
(FM). In particular, there is a need for a clear
understanding of the role of GP/FM in many
countries of central and eastern Europe
and some other countries trying to improve
professional support for the development of the
primary healthcare concepts.”4
A similar concern is voiced by Mark T.
O’Connell et al, who states, “The modern
 160  Section 4: The Practice of Family Medicine
healthcare delivery system is complex and
rapidly changing. The role and responsibilities
of physicians are evolving with these changes,
requiring new knowledge and skills for today’s
and tomorrow’s physicians. To optimally manage
the care of individuals and groups of patients,
physicians must understand how systems of
care function, and how to effectively use those
systems. Managing the care of individuals
and populations often requires physician
participation in team-based efforts. High-quality
and effective clinical practice in this environment
requires a physician to be a member, and often
a leader, of many teams that must work together
to deliver health care in the United States.”5
Changing Leadership Competency
It is evident that the medical education and
health departments are undergoing as much
change as any part of an institution. This is
especially true for family physicians in academic
health centers. Medical schools are restructuring
their curricula at all levels to provide integrated
cost effective health care to the population
(Table 19.1). Teaching hospitals and medical
centers are growing up to conduct health
services and outcome research that they ignored
completely until very recent times.6, 7
Table 19.1  The proposed six key leadership
competency domains
1. T echnical skills and knowledge (regarding
operational, financial, and information systems,
human resources, and strategic planning),
2. Industry knowledge (e.g. regarding clinical
processes, regulation, and healthcare trends),
3. P roblem-solving skills (to understand the
problem, create a plan to solve the problem,
seeing the plan through and reviewing the plan
to ensure that the problem is solved and is not
repeated),
4. Emotional intelligence (the ability to perceive,
control, and evaluate emotions),
5. Communication (to communicate effectively;
to carry out the thoughts and visions of an
organization to the people), and
6.  Commitment to life-long learning.
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Further, family physicians with appropriate
skills are called on to guide students groups,
residency programmes, hospital departments,
managed care organizations, university
departments, professional groups and political
organizations in building the stature of
family medicine.8 No one really knows what
medical practices, academic health centers,
medical training programs, clinical services,
or research will look like in 5 years, let alone
25 years from now.9
In such challenging times, wherein health
care is delivered by complex systems, often
involving large number of individuals and
organizations, it is especially important to
be able to imagine quickly and in detail, the
possible sequences of events leading to a very
different organization than currently exists.
It is important to understand the mission,
needs, strength, and weaknesses of one’s own
organization, and quickly create a favorable
scenario out of rapid changes. We need a fresh,
enduring strategy for viewing our potential
and mapping our goals—goals that are truly
worthwhile, believable and achievable.
Physicians as Better Leaders
In the present set up of healthcare system,
with the establishment of family medicine as
a specialty, and its institutionalization in an
academic faculty, who can make this happen?
Who can perhaps be nurtured to be the “leader”
with character traits such as integrity, creativity,
dedication, competency, assertiveness,
humility and magnanimity, and also inspire
others, assist in times of crisis, work within the
ethical framework, and impart knowledge and
teach colleagues?10,11 In a medical organization,
it has to be a physician, because, as a rule the
entire staff and organization looks to him or
her for leadership, guidance and vision. “It is
common knowledge that doctors have become
leaders in various sectors of society. One of
the fundamental advantages a doctor has

over others in leadership positions is his basic
training in studying and understanding human
nature. With years of practice and experience,
the doctor, a student of human nature, has
a good grasp of human behavior which
enables him to become a better leader”.12,13 Jeri
Hepworth, PhD, in her presidential column
titled,” Leadership for the Future of Family
Medicine: STFM’s People and Power” states, “It
is not an accident that many in family medicine
are being asked to take on leadership roles
in our medical schools, hospitals, and health
care agencies. The skills of family phy­sician
educators are needed at all levels, and we can
no longer wait to be asked. The stakes are too
high. Be­cause we are passionate about medical
education and the future of health care, we
have a responsibility to seek these increased
leadership positions.”14
Developing Physician Leaders
Leadership is critical in medical practice not
only because of a line up of patients and staff
expect it, but because quality improvement,
particularly quality service and patients’
safety, which entail through planning and
execution, demand leadership.15 The factors
that underscore the need for developing
physician-leaders include:
™™ Physicians may lack inclinations to
collaborate and to follow
™™ Healthcare organizations pose challenging
environments in which to lead
™™ Traditional criteria for advancement in
medicine regard clinical and/or academic
skills rather than leadership competencies
™™ Little attention is currently given to
training physicians regarding leadership
competencies.4
*Ref. Appendix 7 “Distance education programme for physicians to become” “physician leaders in
healthcare”—JIMA-March 2011; vol. 109, No 3,p.ii.
web link < http://www.expresshealthcare.in201009/tradetrends01.shtml> Accessed on 18-11-2011
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Chapter 19: Leadership 161
The traits demanding high leadership
qualities may appear daunting to physicians
who have received at best informal training in
leadership. The demands of being a competent
physician, as well as community and academic
leader are too rigorous for most physicians
to assimilate in a causal manner. As a result,
many physicians shy away from a role in which
they could make a tremendous impact.16
Actually, most leaders are made, not
born. As former President of United State
Eisenhower told his son, “The one quality that
can develop by studious reflection and practice
is the leadership of men”.9 While physicians
may not have extensive experience or formal
training in leadership, they can build on the
skills they use daily in clinical practice to
become a highly effective leader in any setting.
Therefore, leadership skills should be part of
health services administration programs in
schools of public health, which should see
their mission as helping to identify and train
leaders, not simply technical specialists in
management.17,18 The 1999 American Academy
of Physician Assistants (AAPA) Leadership
Project Task Force Report (adopted 2003)
states, “Leadership skills can be learned
through a variety of methods and media,” and,
“becoming a good leader is a lifetime process,
not a certification* (Table 19.2).”19,20
Table 19.2  The top eight learning objectives related
to leadership from the highest rank in descending order
1.  Leadership theories, styles, and functions
2.  Team building
3.  Working with others
4.  Strategic thinking
5.  Strategic analysis and planning
6.  Motivating and empowering
7.  Conflict management
8.  Conducting a meeting
Source: Leadership Advisory Commission survey of
155 AAPA leaders
 162  Section 4: The Practice of Family Medicine
Characteristics of Leadership21
Leaders Look Forward
Leaders examine the current situation, look
ahead to future possibilities, and recognize the
need for improvement. They then create a new
system, or change the system from what it is to
what it should be. In keeping pace with rapid
changes, they introduce modern methods that
increase effectiveness and efficiency, lower costs,
and encourage ideas to enhance productivity.
They learn how, why, and where things are
changing, so that they can expect the possibilities,
create fresh avenues and opportunities.
Leaders Define Reality
Leaders often substantiate facts and figures
with evidence. Problems are analyzed to the
core and required information sorted out. The
results are put into action, which become a
powerful stimulus for improvement, resulting
in enhanced performance.
Leaders Take Initiative—Take Risks
Whatever they are trying to accomplish,
leaders take control of the situation and act
on their own convictions. They seek the work
they like, or from which they can learn. They
view mistakes as learning opportunities. They
are skilled at critical thinking, and can find
possible reasons to reject a new idea. Leaders
take that risk. Taking risks builds resistance
and self-confidence, which helps empower
them to strive toward a leadership position.
Leaders Like Colleagues,
Professionals, and People
The best leaders care about people. They
show sincere interest in what others are doing,
and this recognition makes people feel good
about them and about the leader. They are
approachable. The best leaders are humane.
They recognize their own weaknesses, which
makes them more understanding of the
weaknesses of the others.
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Leaders are Self-confident
Self-confidence, self-assurance, self-
conviction are the hallmarks of a strong leader.
There is magnetism about these leaders who
are sure of themselves without having to say so.
The simple appearance of confidence builds
trust and a feeling of security in people who
report to them. It also builds trust and security
in the people who supervise them.
Leaders are Courageous and Decisive
Leaders try new ways to do something because
they might be better. They don’t say, “We don’t
do it that way”, without a very good reason. And
if the event fails, or a certain method doesn’t
work, leaders don’t lose faith or lay blame.
When all the information is available, the
correct decision is usually obvious. The tough
decisions are when all the data isn’t available
and a decision has to be made any way. It takes
courage to make a decision that could be wrong.
Delay in decisiveness, procrastination is all clear
messages that the leader is demoralized, and no
one respects or follows a demoralized leader.
Leaders Maintain Integrity
Integrity is the single most important
characteristic of competent leaders; it is the sine
qua non of a trusted and effective leader. People
are willing to be led by someone who is honest.
Being honest isn’t a matter of not lying—it is
taking the extra effort to display honesty. They
acknowledge their mistakes and admit failures
when something did not work. They do what is
promised, and don’t promise what they can’t.
People without integrity and honesty may gain
power, but they don’t truly lead.
Leaders are Preservers
Persistence in the face of adversity is one of
the cornerstones of resilience. Leaders stay
resolute in their values and goals. They remain
determined and self-disciplined in their efforts

to achieve them. Persistence doesn’t mean
they feel discouraged. Rather, they remain
focused on the goal in spite of their feelings
of discouragement. They keep going because
they believe in what they are doing.
Leaders are Teachers
Throughout history, leaders have naturally
served as teachers, coaches and mentors,
and it is important to realize that the teaching
goes beyond just the job at hand. Leaders
disseminate the skills of leadership as well, and
prepare the next generation of leaders for their
organization, and thus help people to develop
self-confidence, ambition, honesty, integrity,
courage, enthusiasm, and many such fine
qualities essential for successful leadership.
Tools for Leadership
The process of leadership is not something
that can take place overnight. It needs hard
work, perseverance, and a strong desire to
improve—a desire to become an achiever. For
this, one needs to plan in earnest and define
the kind of improvements you wish to see in
the organization. Some useful methods to
achieve these objects are:
Create Your Vision and a Mission
Statement
Successful leaders create a compelling vision
that gives a sense of direction and purpose.
It is a picture of the future to which you
can commit. It expresses your values, the
contribution of the team mates want to make,
and the way the organization or the objectives
have to progress for desired outcome. An
example of visionary statement could be:
“To develop outstanding family physicians who
have excellent clinical and communication
skills; to emphasize patient dignity, personal
responsibility and health maintenance as
concepts critical to optimal healthcare, and
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Chapter 19: Leadership 163
to fully integrate family physicians into multi-
disciplinary healthcare team.”
A leader is committed to this vision, and
inspires others to action by analyzing their
goals with this vision. Without a clear vision,
it’s easy to be lead by the expectation of others.
Establish an Advisory Board
Although, medical profession puts a premium
on self-reliance, everyone needs guidance and
support. Some organizations retain old leaders
as advisors or mentors.
One of the key assets of effective leadership
is having the right person in the right job,
encouraging desirable behavior in others.
It enables to obtain assistance from several
experts. Each has a unique contribution to
make, without burdening any other person.
Establish Network
As the knowledge is expanding exponentially
in today’s information technology, it is
essential to have an efficient network. It
enables to obtain updated information by the
fastest route that may be essential in urgent
matters.
Become an Excellent Communicator
A leader must communicate the vision in a
way that energizes people and galvanizes
them toward action. The ability to gain the
cooperation and support of others through
negotiation, persuasion, and influence
depends upon communication skill, which is
essential for leadership.
Group Discussion
Group discussion is one of the best ways
to enlisting the cooperation to arrive at
best possible solution for any problem. For
example, how will your practice respond
if a new corporate hospital opens in your
 164  Section 4: The Practice of Family Medicine
community area? What is your group doing
to protect your patients’ loyalty? What will
you do to ensure that your group will survive
the competition? What methods can be
implemented to document the enhanced
quality and efficiency of care? What will you
do if your practice is brought by managed
caretakers? These and many other sudden
and unexpected situations demand rapid
responses to evaluate wide range of options
and quick actions. Physicians developing
leadership skills should study and practice
effective communication in the wildest
possible array of settings. They should listen,
read, talk and write as often as possible.
Learn the Rules and Obey Them
Knowledge of the rules is vital. It helps the leader
which decisions he/she can make and which
must be referred to higher authority. Rules make
it possible to figure out how to implement the
vision within the parameters of organization; it
helps to understand where the grey areas are,
and where it might be possible to innovate.
Knowing the rules of the organization and
respecting them is one way a leader can earn
the trust of his/her colleagues and subordinates.
Develop and Maintain a Support System
Taking the time to maintain supportive and
close connections with others, such as role
models, referral agents and personal friends is
necessary to attain and sustain the energy and
well-being you need to achieve career success.
Learn to delegate well. Leaders are clear about
their expectations when giving assignments.
But don’t allow perfectionism to derail good
delegating. Instead, they will help others to
increase their own competence by proper
understanding of their expectations.
Leadership and Power
Leaders must occasionally use power, especially
in circumstances where the leader must
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discipline or even dismiss fellow physicians.
Persistent incompetence, disobeying rules,
or active undermining of work of the team
should never be tolerated. Even though it is
painful to do it, leader must use power in such
circumstance or quality will suffer.
Maintain Balance in Your Life
The best leaders are able to maintain a balance
in their lives. They believe that personal and
family times, as well as a healthy life-style are
their rights. They schedule their activities into
their busy lives on a regular basis.
What Physicians should do When
Asked to Lead?13,14 (Table 19.3)
Asses the Task
First try to get bird’s eye view. As you gaze
down, ask yourself: Whom do you serve?
What is the main thing expected of me? What
facilities and services are presently available?
Are the physicians, nurses, receptionists,
and administrators in harmony with each
other? What is the status of physician-patient
Table 19.3  Ten leadership action steps9
1. Acknowledge and accept your role and
responsibility as leader.
2. Read about leaders and leadership in all fields
and endeavors.
3. Ask others for their opinions and ideas.
4. Listen to the opinion and ideas of others, both
solicited and non-solicited. Implement them
when you can.
5. Don’t be afraid to delegate.
6. Participate in processes when possible.
Demonstrate interest and enthusiasm for staff
events and activities.
7. Recognize the participation and contributions
of others.
8. Be enthusiastic.
9. Make decisions. Then explain them—before,
during or afterward, depending upon the timing
and circumstances.
10. Let others make decisions. Give them authority
and accountability. It’s not power over others,
but “empowering” others.

relationship in the set up? How stable is the
organization financially? What priorities stand
out for quick implementation? As a leader, the
first job is to take a bird’s eye view.
Get to Know Your Customers
In medical practice, the ultimate customers
are not physicians, hospital administrators, or
paramedical staff. They are those who use and
pay for services, namely, patients, employees
and taxpayers. It is essential to evaluate as
accurately as possible how they judge the
services. As a physician leader, you must bring
this reality to your team. Make it a habit to go
to them, invite them to your departmental
meetings, hear what they say, and involve them
in suitable policy decisions.
Physician-Patient Relationship
A physician’s primary responsibility is the
well-being of the patient. Therefore, it is
critical to have a deep understanding of the
nature of the physician-patient relationship.
Let patients know you are interested in them.
Do it with your eyes, your body language, in
any number of ways. Somehow let them know
you are sincerely interested. Spend time in real
conversation with patient, gather useful data,
do statistical analysis, document them in terms
of words, graphs and picture in such a way that
all members of the team share the value of
physician-patient relationship. Ultimately, it’s
not just the knowledge, but also the humane
aspect of their approach to patient’s needs,
aspirations and care that they will notice.
Share Your Vision
An important task is to begin a series of
discussions with team members to share your
ideas and objectives. You can then develop
a “mission statement” that brings everyone
into agreement about the scope of the project
at hand and the purpose of the organization.
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Chapter 19: Leadership 165
Every individual work and responsibilities
should fit into that aim to achieve a common
goal. Leaders in medical practice need to have a
vision of how their practice, residency programs,
departments, hospitals or organizations could
do better. They must be able to communicate
their vision to their customers.
Visit with Your Team
This is sometimes referred to as “management
by walking around”. You cannot know your
practice staff, the work they do, or the patients
you serve if you sit behind your desk. By visiting
various departments and by being frequently
present in the midst of your team’s work, you
gain a real sense of what is wrong and what is
possible. You make yourself available to hear
their concerns, complaints and suggestions.
During the visit ask several questions, such
as—“what is the stock position in drug store?
Has drug expiry check been updated? How
efficient is the central oxygen supply system
in ICU? Why frequent errors are reported in
patient billing system?” An understanding of
working of various departments and ancillary
services is essential. Your regular visits help
keep track of the progress made and evaluate
the team against the standards set.
The Limits of Spoon Feeding
As the physician leader you may be an
excellent diagnostician and a good problem
solver. That does not mean that you should
now solve the other doctors’ problem cases for
them, because you cannot provide leadership
in the form of solutions. You must enable the
people in your office practice to analyze their
problems and find solutions, because as soon
as one improvement is made, there will be a
new problem to solve. If your practice staff
cannot continually improve their work, if your
organization cannot adapt and learn rapidly,
you will have to do all the work yourself.
 166  Section 4: The Practice of Family Medicine
Drive out Fear
An environment of fear or intimidation is
unhealthy in the progress of any organization.
In medical practice, if the nurses’ fears
physicians, and physicians in turn fear
administrators, the ultimate result will be
a mismanaged patient. As a leader, you
must make it clear to your staff that you are
interested in learning the truth, even if it hurts,
and that you are not looking for someone to
blame for problems. As a leader, your role is to
avoid the search for “bad apples”, rather, focus
on improving the processes and systems in
which your physicians work.
Improve Yourself
Self-improvement is the need of the hour.
Leaders have to spend time and effort on
improving their own performance. This can be
achieved by target reading, attending seminars
and workshops, viewing tapes and speaking with
others, who might mentor you. One of the best
ways to learn is simply to observe good leaders,
notice the leadership process—what is the leader
doing to establish harmony and to effect change?
“Look for some one who has that Midas touch,
that Houdini, or Stradivari quality that will really
inspire you, motivate you, and guide you.”22 Act
self-employed, but be a team player. Take “I”,
“me” and “mine” out of your vocabulary. This is
an amazing exercise of self-control. The benefit
of working with a group of people comes when
the synergy among members allows the group
to achieve what no individual could do alone.
Conclusion
Healthcare environment is rapidly changing,
and a growing number of physicians are being
invited to lead clinical and academic medicine.
The skills physicians use in clinical practice
are an excellent foundation for leader’s roles.
The seeds of leadership skills have been
planted in physician’s practice, but they need
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intensive cultivation to flourish which will
enable them to take their right place in the
leadership of medicine for the 21st century.
As physicians develop and practice their
leadership skills, it’s worth recalling the advice
of the Chinese Philosopher Lao Tzu: “The best
of all leaders is the one who helps people so
that, eventually they don’t need him.”
The physician-leader is responsible for
developing future physician-leaders, the great
leader models, mentors, monitors, motivate,
and multiply.
References
1. Lim P. Demands and challenges of modern
medicine. Ann Acad Med Singapore, 2007;
36(8):698–701. [PMID: 17767343:Free Article].
2. Starfield B. The future of primary care
in a managed care era. Int J Health Serv
1997;27(4):687–96. [PMID: 9399113: Abstract].
3. Gérvas J, et al. [Some causes (and solutions)
of the loss of prestige of general practitioners/
family doctors. Against the discrediting of
heroes]. Aten Primaria. 2007;39(11):615–8.
Spanish. [PMID: 18001645: Free article].
4. A charter for general practice/family medicine
in Europe – working draft. Report on a WHO
meeting, Copenhagen, Denmark, 6–7 February
1998.
5. Mark T. O’Connell, et al. Undergraduate
Medical Education for the 21st Century:
Leadership and Teamwork. Fam Med,
2004;36(January suppl):S51-S56.
6. Stoller JK. Developing physician-leaders: a call to
action. J Gen Intern Med. 2009;24(7):876–8. Epub
2009 May 20. [PMID: 19455370: Free full text].
7. Williams SJ. What skills do physician leaders
need now and in the future; Physician Exec.
2001;27(3):46–8. [PMID: 11387895:Abstract]
8. Taylor RB. Leadership is a learned skill, Fam
Pract Manag, 2003;10(9):43–48.
9. Magill MK. Becoming an effective physician
leader. Fam Pract Manag, 1999;6(5):35–7.
[PMID: 10537795].
10. Gustafson RP, et al. Who will lead? Physician Exec.
1997;23(8):37–40. [PMID: 10176685: Abstract].

11. McKenna MK, et al. Development of physician
leadership competencies: perceptions of
physician leaders, physician educators and
medical students. J Health Adm Educ, 2004;
21(3):343–54. [PMID: 15379370: Abstract].
12. Woo KT. leadership. Singapore Med J, 2007;
48(12):1069–73. [PMID: 18043833: Free Article].
13. Reinertsen JL. Physicians as leaders in the
improvement of health care systems. Ann
Intern Med, 1998;128(10):833–8. [PMID:
9599196: Abstract].
14. Hepworth J. Leadership for the future of family
medicine: STFM’s people and power. Fam Med,
2011;43(6):442–4. [PMID: 21656404: Free Article].
15. Brown SW, et al. Lighting and leading the way.
In: Patient satisfaction pays. Aspen Publishers,
Inc. Maryland 1993.pp.48.
16. Darosa DA, et al. Barriers to Effective Teaching.
Acad Med, 2011;86(4):453–9. [PMID: 21346500:
Abstract].
17. Legnini MW. Developing leaders vs training
administrators in the health services. Am J
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Chapter 19: Leadership 167
Public Health, 1994;84(10):1569–72. [PMID:
7943472. Free full text].
18. Kuo AK, et al. An innovative residency program
designed to develop leaders to improve
the health of children. Acad Med, 2010;
85(10):1603–8. [PMID: 20703151: Abstract].
19. Martins HM. Why management and leadership
education for internists? Eur J Intern Med, 2010
Oct; 21(5):374–6. Epub 2010 Jul 13. [PMID:
20816587: Abstract].
20. Goldstein AO, et al. Teaching Advanced
Leadership Skills in Community Service
(ALSCS) to medical students. Acad Med, 2009;
84(6):754–64. [PMID: 19474554: Abstract].
21. Legnini MW. Developing leaders vs training
administrators in the health services. Am J
Public Health, 1994;84(10):1569–72. [PMID:
7943472. Free full text].
22. Terri Sjodin—author, speaker, consultant,
and the principal and founder of Sjodin
Communications.
 20 Addressing
Medical Errors

“The physician must have two special objects in view with regard to disease,
namely, to do good or to do no harm”
—Hippocrates

Introduction risks inherent in medical practice, and

One of the most basic and oft-repeated
quotations in medical lore, Premium non-
nocere, i.e. first do no harm—a mandate
among physicians which has been an
expression of hope, intention, humility, and
recognition that acts with good intentions may
have unwanted consequences, and places the
welfare of the patient above other concerns—
is one of our medical profession’s guiding
principles. But, in reality, most of us who look
back on our careers realize that medicine is a
human endeavor, and in fact most physicians
do make mistakes.1 Although the vast majority
of patients who have access to medical services
today are healed, there are some, however,
who suffer unintended consequences of care. 2
The dictum often quoted in medical profession
is that every physician is vulnerable to errors,
irrespective of competence and care. Many
errors in health care are unknown and the total
number may be unknowable.3
The inevitability of adverse events* in
medicine arises from human fallibility,**
negligent care, limits of medical knowledge,
biological variability among individuals.4
Although technology is helping in some
ways, it is also causing a growing risk of new
unexpected adverse events. As Bernard
Lown, MD, winner of the noble peace prize
states emphatically in his book, “The lost art
of healing”, “The reason for this shift includes
a romance with mindless technology, which
is embraced in large measure as a means for
maximizing income…diagnosis is performed
by exclusion, which opens floodgates for
endless tests and procedures.” 5 This is a
problem that must be addressed. Even though
not a popular problem in health care, if not
critically tackled, it will get worse in the
future.6 Atul Gawande, Associate Professor
of Surgery at Harvard Medical School, in his
book “Complications: A Surgeon’s Notes on
an Imperfect Science” argues—“Whether all
errors are truly preventable can be debated …
no matter what measures we take, medicine will
sometimes falter, and it isn’t reasonable to ask
that it achieve perfection….what is reasonable
to ask is that medicine never ceases to aim for
it.” 7 Therefore, what should be the attitude of

*The IOM defines “adverse event” as “an injury caused by medical management error rather than the
patient’s underlying disease or condition.”
**“To err is human” is a well-known saying that captures the fallibility of human beings. Humans are
fallible and as such they will make mistakes in their lives and work, be they builders, bankers or doctors.

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 Chapter 20: Addressing Medical Errors 169
the medical profession? Once medical errors
have occurred, and will continue as long as
physicians remain fallible humans, should it
be accepted as a matter of fact and physicians
withhold such information from patients since
“what they don’t know can’t hurt them”; or,
should such information be honestly disclosed
to patients and appropriate measures taken to
redress and prevent any such errors in future?8
New Approach—Acknowledge
Mistakes
Since 1990, several studies have scrutinized
medical error. These publications mark a
break from the traditional secrecy surrounding
mistakes by physicians. A new approach in
medicine encourages physicians to acknowledge
mistakes, both to themselves and to others.9
The US President Mr. Obama, and the Secretary
of State Ms. Clinton, in their article, “Making
Patient Safety the Centerpiece of Medical
Liability Reform”, state: “A safe and appropriately
confidential environment must be created
that allows open communication between
physicians and patients about adverse outcomes.
Initially, medical-error transparency may be
difficult to foster. However, organizations that
have put disclosure programs into practice
have been effective in resolving disputes
in a less adversarial manner, providing fair
compensation, and improving patient care.
We believe that the National Medical Error
Disclosure and Compensation (MEDiC) Bill
provides a common-sense solution that avoids
the political pitfalls that have hampered other
efforts to reform the medical liability system.”10
Medical Errors—Focus on Primary
Care
According to the landmark report released
form Institute of Medicine (IOM) in United
*The report cited two studies, one based on hospital discharges in New York in 1984 and the other based
on discharges in Colorado and Utah in 1992.
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States in November, 199911, it is estimated that,
“... at least 44,000 Americans die each year as a
result of medical errors ... the number may be
as high as 98,000.”
Although the IOM’s estimates have been
criticized, and its validity is being debated,12
it’s to be noted that such mortality statistics are
based on medical errors in hospitals—solely
on inpatients’ errors, and most medical error
research has been performed in indoor hospital
settings.* However, the majority of medical
care is provided in the ambulatory arena, with
an estimated 119.2 million visits to hospital
OPDs and emergency departments, or 40.5
visits per 100 persons during 2006.13 Therefore,
considering the magnitude and the likely drastic
consequences of medical errors on ambulatory
or primary care patients, “it is not possible to
learn about making health care safer for patients
by limiting research to investigations that harm
patients in hospitals only”.14
Thus, in order to broaden the horizons of
medical errors, its health consequences, and
prevention, many health organizations in
Europe and United States have initiated research
to investigate this major clinical issue of medical
errors with its focus on primary care settings,
wherein medical errors are as much an issue as
they are for hospital based providers.8 Hospitals
represent a very small percentage of patient visit.
Outpatient care is significantly more common,
more complex, and much less structured and
regulated. Besides, patients are seldom at risk
of anesthetic or surgical complication as in
hospital setup. So, it seems prudent to ask—are
medical errors equally serious and perhaps
more prevalent in family practice? If so, what
can be done to avoid them?15
Definition
What is a medical error? Despite a growing body
of literature and research on error in medicine,
 170  Section 4: The Practice of Family Medicine
few studies have defined or measured “medical
error”* directly. Instead, researchers have
adopted surrogate measures of error that largely
depend on adverse patient outcomes or injury,**
i.e. they are outcome-dependent (Table 20.1).
One study found 25 different definitions for error
in the medical literature (Table 20.2).16 A lack
of standardized nomenclature and the use of
multiple and overlapping definitions of medical
error have hindered data synthesis, analysis,
collaborative work and evaluation of the impact
of changes in healthcare delivery.17 It’s obvious
that these potential areas of confusion need
further study. However, the American Academy
of Family Physicians National Network for
research in family practice and primary care
Table 20.1  Glossary
Adverse Bad patient outcomes due to adverse
event drug-effects, nosocomial infections,
improper transfusions, retained objects,
decubitus ulcers, wrong-site surgery,
peri-operative myocardial infarction, IV
line and catheter infections.
Error "The failure of a planned action to
be completed as intended (error of
execution) or the use of a wrong
plan to achieve a medical outcome
(error of planning). Errors can include
problems in practice, products,
procedures, and systems."
Outcome or Procedure that identifies potential
Root-cause causes of error within three main
analysis domains of cause:
•  Human or cognitive error (e.g. error
in judgment)
•  Organizational or system error (e.g.
insufficient staff)
•  Technical or engineering error (e.g.
inexperienced operator)
*A medical error is failure of a planned action to be completed as intended or the use of a wrong plan to
achieve an aim.
**Adverse events, on the other hand, can be defined as harm resulting from the process of medical care
rather than from the patients’ underlying disease.
It should be noted that the vast majority of medical errors are not associated with an adverse event (i.e.
do not cause harm). Similarly, most adverse events are not associated with a medical error and therefore
are not preventable.
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has created an elegantly simple and functional
definition of medical error. It is “…. an error is
defined as: something in your own practice that
should not have happened and that makes you
Table 20.2 Assorted medical error definitions from
medical literatures
• A failure to meet some realistic expectation (an
action, process, diagnosis or endpoint) (Cosby KS)
• An act of commission or omission that caused, or
contributed to the cause of, the unintended injury.
(Wilson RM, et al)
• An act of commission or omission that
substantively increases the risk of a medical
adverse event. (Hayward RA, et al)
• An adverse event or near miss that is preventable
with the current state of medical knowledge.
(Foundation NPS)
• An unintended event, no matter how seemingly
trivial or commonplace, that could have harmed
or did harm a patient. (Bhasale AL, et al)
• An unintentional deviation from standard operating
procedures or practice guidelines.(Segen JC)
• Anything that happened in your own practice
that should not have happened, that was not
anticipated and that makes you say, "That should
not happen in my practice and I don't want it to
happen again.(Dovey SM, et al)
• Error…A commission or an omission with
potentially negative consequences for the patient
that would have been judged wrong by skilled
and knowledgeable peers at the time it occurred,
independent of whether there were any negative
consequences. (Wu et al)
• Errors in healthcare are by definition, human
errors, and human errors are errors in human
actions.(Zhang J, et al)
• Failure to meet reasonable expectations for goal-
directed activity.(Pani JR, et al)
• Preventable incidents that result in a perceived
harm. (Kuzel AJ, et al)
• The failure of a planned action to be completed
as intended (i.e. error execution) or the use of
a wrong plan to achieve an aim (i.e. error of
planning). (Forum NQ)
• The failure of planned actions to achieve their
desired goal. (Reason J)
 Chapter 20: Addressing Medical Errors 171
say: ‘that should not happen in my practice, and
I don’t want it to happen again’; it can be small
or large, administrative or clinical—any thing
that you identify as something to be avoided in
the future.”8
Types of Errors
Most people believe that medical errors usually
involve drugs, such as a patient getting the wrong
prescription or dosage, or mishandled surgeries,
such as amputation of the wrong limb. However,
there are many types of medical errors. The
following seven categories summarize types of
medical errors that can occur:
™™ Medication errors, e.g. a patient receiving
the wrong drug.
™™ Surgical error, e.g. amputating the wrong
limb.
™™ Diagnostic error, e.g. misdiagnosis leading
to an incorrect choice of therapy, failure
to use an indicated diagnostic test,
misinterpretation of test results, and failure
to act on abnormal results.
™™ Equipment failure, e.g. defibrillators with
dead batteries or intravenous pumps
whose valves are easily dislodged or
bumped, causing increased doses of
medication over too short a period.
™™ Infections, e.g. nosocomial and post-
surgical wound infections.
™™ Blood transfusion-related injuries, e.g. a
patient receiving an incorrect blood type.
™™ Misinterpretation of other medical orders,
e.g. failing to give a patient a salt-free meal,
as ordered by a physician.
Leape et al have characterized the types
of errors that resulted in medical injury in the
Medical Practice Study as diagnostic, treatment,
preventive, or other errors (Table 20.3).
Classification
Errors can be classified as:
™™ Errors of commission, i.e. patients are
harmed as a consequence of, “What is done
to them”; For example:
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ƒƒ Wrong diagnosis.
ƒƒ Improper management of correct
diagnosis.
ƒƒ Prescription errors, such as wrong
drug, wrong dosage or duration, failure
to recognize drug-drug interaction,
illegible prescription, etc.
ƒƒ Failure to monitor drugs that require
monitoring, such as digoxin, Insulin,
anticoagulants, etc.
™™ Errors of omission, i.e. patients are harmed
as a consequence of, “What is not done,
but should have been done to prevent an
adverse outcome”; for example:
ƒƒ Failure to follow-up a test result, such
as Pap smear.
ƒƒ Failure to inform patients of test result.
ƒƒ Lack of necessary follow-up with
physician.
ƒƒ Failure to coordinate care with
consultants.
ƒƒ Delay in diagnosis.
ƒƒ Failure to provide proven disease-
specific care.
ƒƒ Failure to perform preventive care.
Table 20.3  Types of medical errors
Diagnostic
•  Error or delay in diagnosis
•  Failure to act on results of monitoring or testing
•  Failure to employ indicated tests
•  Use of outmoded tests or therapy
Treatment
•  Avoidable delay in treatment or in responding to
an abnormal test
•  Error in administering the treatment
•  Error in the dose or method of using a drug
•  E rror in the performance of an operation,
procedure, or test
•  Inappropriate (not indicated) care
Preventive
•  Failure to provide prophylactic treatment
•  Inadequate monitoring or follow-up of treatment
Other
•  Equipment failure
•  Failure of communication
•  Other system failure
Source: Leape, Lucian; Lawthers, Ann G; Brennan,
Troyen A., et al. Preventing Medical Injury. Qual Rev
Bull. 1993;19(5):144–9.
 172  Section 4: The Practice of Family Medicine
Understanding Errors in Family ™™ Errors due to gaps in “knowledge and
Practice skills”, (e.g. wrong diagnosis or treatment)
accounted for a minority of errors—just
The majority of people in a primary care
14%.
setting or family practice receive high quality
™™ Errors due to “System Failure”* accounted
care but, unfortunately, for some people, this
for 86%. These included lapses in patient
care may be potentially harmful. This could
follow-up, misfiling and/or never
be due to variety of factors that characterize
documenting receipt of lab work or
family practice, such as multiplicity of health-
consultations, miscommunication among
care providers and patient consultations.
families, physicians and patients, lack of
The IOM report highlights this problem as,
coordination among physicians’ offices
“the decentralized and fragmented nature
and hospitals, emergency department,
of the health care delivery system—or non-
skilled nursing facilities and home care.
system to some observers. When patients see
The physicians reported that 44% of their
multiple providers in different settings, none
errors led to adverse events; ten errors
of whom has access to complete information,
resulted in patients being admitted to
it becomes easier for things to go wrong”.
hospital and one patient died.
Furthermore, in a typical busy family practice,
In a similar group of studies 19 about
it’s impossible for physicians to give totally
medical errors in family medicine, the five
accurate medical care when only a brief time
error types most often observed and reported
is available for appointments for each patient.
by US family physicians were:
The IOM report concludes that, “the
™™ Errors in prescribing medications,
majority of medical errors do not result from
individual recklessness or the actions of a ™™ Errors in getting the right laboratory test

particular group—this is not a “bad apple”
problem. More commonly, errors are caused
by faulty systems, processes, and conditions
that lead people to make mistakes or fail to
prevent them.” This is illustrated in a study
in primary care office of US family physicians
which was designed to develop a preliminary
taxonomy of primary care medical errors.18
In this study the qualitative analysis of 344
medical reports made by 42 physicians were
quiet different in character than hospital based
medical errors:
done for the right patient at the right time,
™™ Filing system errors,
™™ Errors in dispensing medications, and
™™ Errors in responding to abnormal
laborator y test results. “Er rors in
prescribing medications” was the only
one of these five error types that was also
commonly reported by family physicians
in other countries.
Most studies show that poorly designed
“processes of care,”** and not individual
physicians’ mistakes are the primary cause of

*“System” means any group of people (e.g. physicians, nurses, programmers); objects (e.g. signs,
equipments, computer system); and knowledge (e.g. medical training, hospital procedures) that come to
play in a particular healthcare process. The American Heritage Dictionary defines a system as "a group of
interacting elements functioning as a complex whole."
**Desired processes of care includes: the need for convenient access to providers (telephone, internet or
in person); clear communication of individualized care plans; support from a single coordinator of care
who can help prioritize their competing demands and continuity of relationships; providers who would
listen to and acknowledge their needs, appreciate that these needs are unique and fluctuating, and have
a caring attitude.

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 Chapter 20: Addressing Medical Errors 173
error (Table 20.4). As the IOM report quoted
above stresses, “the problem is not bad people in
health care — it is that good people are working
in bad “systems” that need to be made safer.”
Although the major aspects contributing
to medical errors are due to system and
deficiencies in the process of care, it’s a
common knowledge that some share of
medical errors and mistakes are also due to
both physicians’ and patients’ behaviour and
approach to their illness (Table 20.5).
Why should Doctors Disclose
Medical Errors
Practice of modern medicine all over the
world is governed by a code of conduct and
Ethics. It symbolizes the principles by which
a group defines itself. Ethical guidelines are
very essential for medical profession, as this
profession handles the power of healing and
deal with life and death.
The cornerstone of medical ethics is the
distinctive fiduciary nature of physician-
patient relationship.20 A fiduciary is, “one who
pledges to maintain a high-degree of trust,
loyalty, and truthfulness when acting on behalf
of the beneficiary”. As a fiduciary relationship,
it must rely on principles of autonomy,
beneficence, non-maleficence, justice, and
fidelity at all times.21
Table 20.4  Errors in the system and process of care
• Types of errors the system and process of care:
– Administrative error
– Communication error
– Equipment malfunction
– Failure to prevent injury
– Incorrect laboratory results
– Medical procedure error
– Medication errors
– Technical errors
• Primary cause of error:
– Carelessness/negligence
– Communication gap
– Misread prescription or pharmacy error
– Overworked staff
– Untrained staff/incompetence
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These principles, in a nutshell, essentially
mean that the physician is merely an advisor,
who can opine and suggest and not `force’ any
form of therapy. The physician is obligated
to help patients attain their own interests
and goals as determined by the patient. The
time-honoured principle of “do no harm,
prevent harm, and remove harm” should guide
physicians while suggesting a treatment plan.
Every patient deserves and must be provided
optimal care as warranted by the underlying
medical condition and futile treatment and
interventions that have no patho-physiologic
rationale need not be performed.
Table 20.5  Physician’s and patient’s traits in medical
errors
Physician’s:
• Casual attitude: everyone makes them, even the
best physicians
• Substance abuse: physicians who are drunk or
on illicit drugs
• Poor handwriting: causing errors in filling pre­
scriptions or tests
• Poor dosage instructions: difficult to read
numbers, e.g. zeroes, decimal points—can cause
dispensing wrong dosages
Patient’s:
• Delayed or failure to report symptoms: not
disclosing to the physician all their symptoms for
various reasons (embarrassment, thinking it will
be irrelevant, the doctor didn't specifically ask
about it, denial that something is wrong, etc.)
• Failure to report other medications they are on,
either prescription or over-the-counter medi­
cations
• Failure to report other alternative medicines they
are taking
• Failure to read medication labels and instructions
fully
• Non-compliance with treatment plan or medi­
cations: over-looked medications, financial
troubles, laziness, etc.
• Dishonesty of patients: faking or malingering
factitious syndromes to obtain restricted drugs,
insurance fraud, getting time off work, etc.
• Fear of legal issues: e.g. failure to admit to taking
illicit drugs
• Fear of social issues: e.g. failure to admit to
lifestyle or social habits
• Fear of doctor's scolding: e.g. failure to admit to
not following treatments
 174  Section 4: The Practice of Family Medicine
It is, therefore, abundantly evident that
the physician has a multifold ethical duty to
admit mistakes to the patient. The current
opinion of American Medical Association’s
AMA’s Code of Medical Ethics clearly states, “
It is a fundamental ethical requirement that a
physician should at all times deal honestly and
openly with patients … Situations occasionally
occur in which a patient suffers significant
medical complications that may have resulted
from the physician’s mistake or judgment….
in these situations, the physician is ethically
required to inform the patient of all the facts
necessary to ensure understanding of what
has occurred. Only through full disclosure
is a patient able to make informed decisions
regarding future medical care”.22
Timely and openly disclosing an error or
mistake would benefit patients. Knowledge
of an error could affect the patient’s decisions
regarding future care. The patient may even
cooperate to facilitate physician’s management
to mitigate the burden of errors. Further,
physician’s candor about error may lessen,
rather than increase the medico-legal liability.
Patients have a right to know about critical
incidents even if they are not physically harmed
them. An important patient right is informed
consent. This means that if a patient needs
a treatment, the healthcare provider should
give the patient the information the patient
needs to make a decision.23 Non-disclosure of
medical errors, therefore, interferers with the
doctrine of informed consent since patients
may not understand the reason or need for
additional interventions to rectify undisclosed
errors. It is, therefore, important to disclose
errors in order to respect autonomy and
facilitate the process of informed consent.
Why Doctors do not Disclose
Errors (Table 20.6)
Although most doctors believe that errors
should be disclosed to patients when they
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Table 20.6  Reasons for non-disclosure of errors
Fear:
• Fear of legal liability
• Fear of being blamed for negative patient outcome
• Fear of reprimand from physicians
• Fear patient will develop negative attitude
• Fear of “telling” on someone else
Understanding:
• Confusion over definition of error and near misses
• Disagreement with the organization’s definition of
error
• Providers unaware that errors occurred
• Providers’ bias about which incidents should be
reported
• Some incidents, i.e. near misses, thought too
trivial/unimportant to report
• No perceived benefit
Administrative/Management/Organization:
• Lack of feedback on reported errors
• Persistent culture of blaming the individual
• Slow or poor administrative response to errors
Burden of effort:
• Reports take too long to complete
• Providers forget to make a report, too busy
• Contacting providers take too much time
• Extra work involved in reporting
Source: Patient safety and quality. From Chap. 35-Error
reporting and disclosure-an evidence-based handbook
for Nurses, ed. Ronald G. Hughes, Rockwell, April
2008, Publication no. 08-0043. (PMID: 21328753: Free
full text).
occur, in reality, most doctors (and institutions)
do not disclose such mishaps to patients and
their families. Recent studies suggest that,
although the malpractice environment in
many organizations and countries such as
Australia, Canada, the United Kingdom, New
Zealand, and the United States is clearly
changing toward supporting physicians in
effective and full disclosure of error, harmful
medical errors are infrequently disclosed
to patients.24 Incidentally, some healthcare
groups subdivide medical error into cases
that are not medically remediable and those
that are medically remediable. 25,26 In the
former non-remediable errors, physician’s
disclosure should occur for all errors that
involve significant harm to the patient case;
 Chapter 20: Addressing Medical Errors 175
and in the latter case, where there has been
an error but the patient only experienced
minor, reversible harm that can be easily
corrected, physicians fear that mentioning
the error would damage the relationship with
the patient, and this relationship is important
to the patient’s well-being. However, there is
a significant gap between these beliefs and
actual practice since currently, disclosure
occurs in only about one-third of these cases.
Research has clearly indicated that there
are three barriers to disclosure of harmful
errors:27
First, coping with medical error when it has
occurred is never easy. Emotions and feelings
such as vulnerability, fear of criticism, anxiety,
etc. significantly erode self-esteem as well as
self-confidence, which make disclosure of
errors difficult. Revealing an error to a patient
is often difficult and painful for the physician.
The patient may become angry and upset,
and such reactions can be highly stressful to
physicians.
Second, the fear of retaliation. Many
physicians fear that disclosing a serious
medical mistake will expose them to the risk
of malpractice suit, with the added financial
burden of increased malpractice premiums.28
Further, subsequent to disclosure of medical
error, physicians fear loss of referrals, hospital
admitting privileges, and even licensure.
But doctors often fail to realize that a policy
of honesty and active disclosure of adverse
events has been shown to reduce malpractice
claims.29
Third, physicians fear, often justifiably, that
media may use their incident as fuel to fire a
campaign against medical profession. Media
can wreck professional careers of doctors
when it reports genuine mistakes and errors
in judgement as negligence. Public perception
and reporting of medical malpractice is now
very common. In the last 20 years, the health
system has evolved in a way that it now “allows”
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the criticism of the public and the freedom of
the media…still, legal channels are even now
too slow in resolving such cases.30 However, not
withstanding the media hype, sweeping errors
under the carpet undermines public trust in
medicine because patients feel that doctors
are more interested in protecting themselves
and their colleagues than their wellbeing. This
is a breach of professional ethics—a lapse in
the obligation to act only for the patient’s best
interests.
System Redesign in
Family Practice
The landmark Institute of Medicine report
stating that—“The majority of medical errors
do not result from individual recklessness
or the actions of a particular group …more
commonly, errors are caused by faulty systems,
processes, and conditions that lead people to
make mistakes or fail to prevent them; thus,
mistakes can best be prevented by designing
the health system at all levels to make it
safer—to make it harder for people to do
something wrong and easier for them to do it
right; but when an error occurs, blaming an
individual does little to make the system safer
and prevent someone else from committing
the same error”—has focussed the attention of
healthcare professionals on improving patient
safety through changes in “systems” of care.
These reports resulted in a new paradigm
that, rather than centering on individual
errors, focuses on the “systems” is necessary
to facilitate and enhance quality and protect
patients. Leape, an internationally recognized
leader of the patient safety movement suggests
three features of a system: first, it needs to be
objective, i.e. it needs to be based on data
and objective information and not opinion
or personal feelings; second, it needs to
be scrupulously fair, involving everyone’s
performance, and not to be a stigmatizing
event; and third, it needs to be responsive both
 176  Section 4: The Practice of Family Medicine
in terms of getting information back to the
physician and in terms of taking action when
it is needed.31
If errors result from system failures, not
people failures, and that achieving acceptable
levels of patient safety will require major
system changes, what role can individual
physician play in rectifying the situation?
The following five basic principles of system
redesign as suggested by Leape32 are:
Reduce Reliance on Memory
The medical system relies heavily on physician’s
memory. Physicians must remember diagnostic
criteria, treatment options, dosage schedules,
monitor medicines, test reports, preventive
measures, and many such patient related
records. By making a conscious habit of
entering such items in checklists, reminders,
computer aids help ease this burden.
Improve Information Access
I m p rov e d a c c e s s t o p at i e nt-s p e c i f i c
information, such as treatment charts, test
results, and to knowledge database, such as
electronic text books references, drug index,
allow physicians to have all the information
needed at the point of care so that they can
make the right decision in a timely fashion.
Strive for an Error-proof System
The various systems operating in physician’s
office or a healthcare delivery unit should
work efficiently and in tandem. The systems of
physicians, laboratory, pharmacy, etc. should
communicate directly with all the updates
belonging to the patient. A computer alert-
system should be incorporated in various
systems as a safe guard to prevent any errors.
Standardize Processes of Care
A uniform approach to patient’s health
problem which is documented serially in a
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standardized format minimizes inappropriate
variation in practice procedure that can
lead to errors. Every system operating in
the physician’s office must have its own
standardized protocol, which must be followed
meticulously.
Emphasize Error Avoidance when
Training Medical Staff
Physicians and health care units should
provide thorough training to its staff that
focuses on possible errors and emphasizes
methods to them. A proper knowledge of the
ground rules, use of checklist to ensure that
nothing is forgotten, and periodical orientation
programs provide office medical staff the
necessary skills to recognize potential for error
and to address errors when they do occur.
Apology as a System of Medical
Error Disclosure
Apology is an important expression of empathy.
Offering an apology for harming a patient
should be considered to be one of the moral
responsibilities of the profession of medicine.
An apology includes acknowledgment of
the mistake or wrongdoing, acceptance
of responsibility, expression of regret, and
assurance that the offense will not be repeated.
Brown SW et al, in their book titled “ Patient
Satisfaction Pays”, call this as “Triple-A Action
Plan”, which includes three steps, namely,
Acknowledge, Apologize, and Amend,
(Fig. 20.1) for service recovery. 33 An authentic
apology must include repentance, which
encompasses two essential elements: the
expression of sorrow and the admission of
wrongdoing. The absence of either, renders the
apology incomplete and thus transforms it into
a “botched apology.”34 Indeed, the botched
apology not only fails to inspire forgiveness
but instead may create even further harm and
fuel bitter vengeance.
 Chapter 20: Addressing Medical Errors 177
Fig. 20.1  Triple ‘A’ action plan—steps to service
recovery
When medical errors occur, an apology from
the attending physician can be beneficial to the
patient/family and the healthcare provider(s).
The purpose of the apology is to convey a
human, compassionate, and empathetic
response to the patient’s misfortune. Such
conduct by the physician is reasonable, and
indeed, apology in the setting of medical errors
is becoming increasingly acknowledged by
governments and codified in law.35
Full and honest disclosure of errors is most
consistent with the mutual respect and trust
patients expect from their physicians. Most
patients’ families are incredibly forgiving if they
are informed about a situation that may have
resulted in an error. They are even more forgiving
if they get a personal apology. It doesn’t have to
be an acceptance of guilt, just an “I am/we are…
so sorry that this event has occurred to you.”*
An apology can have profound healing
effects for all parties. Apology by a com­
passionate physician benefits the patient
by easing the worry, decreasing anxiety,
and alleviating confusion, thereby causing
immediate and significant positive effects.
Patients feel that some of their questions
have been answered and are reassured by
their physician’s continuing support. For
*Ref. Chapter no. 30 “Communicating Bad News”, for the details of how to communicate with patients
after adverse outcome.
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the physician, an apology can help diminish
feelings of guilt and shame. For the patient, it
can facilitate forgiveness and provide the basis
for reconciliation.
The process of apology should be followed
by suitable measures (amendments) in trying
to prevent future errors.
A Colorado-based medical liability carrier,
COPIC Insurance Company, has employed
an early intervention program called the “3Rs
program”, standing for recognize, respond, and
resolve. The program emphasizes disclosure,
transparency, apology, and patient benefits.36
Of course, the apology may be extremely
unpleasant, humbling, humiliating, and
may be regarded as a stain on the physician
personally and professionally. The apology
may be misconstrued by the patient as legal
weakness on the physician’s part. It could
be in conflict with the liability insurance
contract. And it might be introduced as
evidence of wrongdoing in court in a
subsequent proceeding.37 Thus, under certain
circumstances, the link between litigation risk
and the practice of disclosure and apology may
be questionable, and for any one physician, the
outcome of a particular error disclosure may
not be so favorable.38,39
Eliminating Errors in Family
Practice—Current Trends
No matter how well organized a practice, how
knowledgeable and understanding the staff
or how quality oriented the attitude, errors
will happen. Therefore, the ultimate purpose
of analyzing errors is to learn how to avoid
them by developing administrative, clinical
and therapeutic systems, which assist family
physicians toward this goal. The following are
some of the important events:
 178  Section 4: The Practice of Family Medicine
Developing Taxonomy of Errors in
Primary Care
The American Academy of Family Physicians
(AAFP), in association with family doctors in
the United States, Australia, Canada, England,
Germany, Netherlands, and New Zealand
have undertaken research project to classify
errors in primary care, chaired by Dovey.
This study will help develop and validate a
classification system which will be useful to
collect, categorize, and analyze errors in family
practice. They have developed taxonomy or
description of medical errors in which there
are more than 500 different types of errors
occurring in primary care practices. As Dovey
emphasizes, “… we can demonstrate that
these are not trivial concerns they can and do
hurt patients, precipitate their admission to
hospitals, and sometimes contribute to their
death. They are important, redeemable, and
they need to be fixed”.12
Establish a Patient Safety Center12
It is a computerized, web-based error reporting
system that meets federal confidentiality
standards. Based on the feedbacks from
physicians, more than 185 practical solution
have so far been offered to medical errors in
primary care. This international study has
given clues into how GP’s in some countries
do things more safely than other countries.
The patient safety center even encourages
physicians to participate even in an
“anonymous error-reporting system”, which
has now become a “powerful method of
promoting positive change in the quality of
care provided by general practitioners”.12
Computerized Disease-specific Health
System
These are customized to patient’s requirements
are now available from private agencies,
*A computer maxim states, “To err is human but to really foul things up requires a computer.”
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e.g. Av Med Health Plan. 40 These devices
are installed at patient’s home and assess
critically various health parameters. The data
is transmitted to physician’s office directly and
the monitoring system gives early warming for
any corrective action to be taken, thus reducing
morbidity and mortality considerably.
Electronic Medical Records (EMRs)41
Today, with the availability of inexpensive
EMRs, family physicians are designing their
own administrative systems to avoid errors
and document the quality of care they provide.
In most contemporary software packages,
different elements of the chart are accessible
through graphic user interface methods
that allow the user to move easily from one
part of the record to another. In addition to
having the ability to enter text, the user can
navigate through the record and gain access to
progress notes, lab reports, insurance forms,
prescription, medications, or perform countless
other clinical and administrative tasks.
An extension of EMR is the “decision
support-system”, which assists physicians
in medical decision-making. “Diagnostic”
decision support systems integrate clinical
findings (e.g. signs, symptoms, and test results)
with disease profiles to produce probability
based pairings of findings and diseases,
while “therapeutic” decision support permit
the physician to generate a patient-specific,
disease-specific treatment plan, including
medication prescriptions, patient education
and diet therapy.
The clinical and administrative staff
will save time by automating repetitive
tasks, reduce malpractice by maintaining
updated, secure, and complete information
for determining a course of treatment, and
improve patient education and compliance.
Although EMRs can help reduce errors,
it can also cause errors.* For example, if two
 Chapter 20: Addressing Medical Errors 179
medications that are spelled similarly are
displayed next to each other, substitution errors
can occur. Furthermore, many computerized
physician order entry systems lack even basic
screening capabilities to alert practitioners to
unsafe orders relating to overly high doses,
allergies, and drug–drug interactions. Also,
clinicians may write an order in the wrong
patient’s record. 42, 43
In a recent systematic literature review,44
based on research papers from 1998 to
2009, conducted concerning barriers to the
acceptance of EMRs by physicians, eight main
categories of barriers, including a total of 31
sub-categories, were identified. These eight
categories are:
™™ Financial: The monetary aspect was an
important factor for many physicians, and
includes those related to the monetary
issues involved in implementing EMRs,
i.e. involving purchasing, coordinating,
monitoring, upgrading, and governance
costs. The questions commonly facing
physicians are whether the costs of
implementing and running an EMR system
are affordable and whether they can gain a
financial benefit from it.
™™ Technical: A certain level of computer skills
by both venders and users (the physicians)
is required. Further, there are still some
technical problems with EMRs, which lead
to complaints from physicians, and they
need to be improved. Therefore, barriers
exist related to the technical issues of the
systems, the technical capabilities of the
physicians and of the venders.
™™ Time: The introduction of EMRs will slow a
physician’s workflow, as it will always lead
to additional time being required to select,
implement and learn how to use EMRs,
and then to enter data into the system. As
a result, their productivity will be reduced
and their workload will be increased. This
can cause financial problems, such as a
loss of revenue.
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™™ Psychological: Physicians have concerns
regarding the use of EMRs that are based
on their personal issues, knowledge, and
perceptions. The physicians without
an EMR doubt that EMRs can improve
patient care or clinical outcomes. Other
researchers have stated that those who are
unwilling to use such a system are skeptical
about claims that EMRs can successfully
improve the quality of medical practices.
This creates a personal resistance to the
adoption of EMRs.
™™ Social: Lack of technical skills and support
from external parties such as vendors,
subsidizers, insurance companies,
patients, administrative staff, and managers
impedes physicians in further adopting the
system.
™™ Legal: EMRs deal with medical information
on patients, and this should be treated
as private and confidential. Physicians
believe that keeping such information
safe is very important, because otherwise
it could create legal issues.
™™ Organizational: Physicians work in
medical practices and hospitals, and the
organizational characteristics of individual
practices will be a factor in the adoption
of EMRs. Physicians in different sizes and
types of practices may well have different
attitudes toward EMRs.
™™ Change Process: Implementing EMRs in
medical practices amounts to a major
change for physicians who tend to have
their own unique working styles that
they have developed over years. This can
make them unwilling to make or adapt to
changes in their work.
In order to study the various aspects
of causes and prevention by computer
information technology, a multinational
research is underway, chaired by Dovey
“This is a critical research for primary care
providers in several countries who are on the
verge of making a wholesale commitment to
 180  Section 4: The Practice of Family Medicine
computerized process (Australia, the US, and
Canada) and for providers in other countries
(New Zealand, England, and Germany), who
have used computers for sometime, but may
be not in the best way.12
Note: Anybody interested in being involved
in the above research project, may please
contact—“sdovey@aafp.org”)
How to Cope with Clinical Errors45
Mistakes are a natural part of practice;
perfectionism is an impossible goal. Hence,
following strategies are helpful in coping with
medical errors:
™™ Accept responsibility for your mistake.
™™ Discuss the error with colleagues,
supervisors, or close family or friends; this
will help you put the error into perspective,
while providing professional reaffirmation
and personal reassurance.
™™ Reveal the error to the patient and offer an
appropriate apology.
™™ Analyze the error.
™™ Implement measures to prevent future
errors.
In order to minimize emotional damage to
the patient and his relatives and to improve the
quality of medical practice, acknowledgement
of having made a mistake comes first.
Thereafter management with respect to the
patient or his relatives should be established
with aid of the group. Guidelines are: make an
appointment with the patient without delay;
take ample time and avoid disturbance; listen
to the patient and respect his feelings; express
regret with regard to the consequences for
the patient; contact the patient again after
an interval to check if new questions have
arisen. This approach is helpful in restoring
the patient-doctor relation after a mistake.
What Patients can Do
Patients are an important resource in lowering
the rate of medical errors. The fact sheet entitled
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“Five Steps to Safer Health Care,”46 developed
by the U.S. Department of Health and Human
Services in partnership with the American
Hospital Association and the American Medical
Association gives following tips to help improve
the safety of their health care.
Ask Questions
Ask questions if you have doubts and concerns,
and make sure you understand the answers.
Take a relative or friend with you to help you
ask questions and understand the answers.
Keep and Bring a List of All the
Medicines You Take
Give your doctor and pharmacist a list of
all the medicines that you take, including
non-prescription medicines. Tell them about
any drug allergies you have. Ask about side
effects and what to avoid while taking the
medicine. Read the label when you get your
medicine, including all warnings. Make sure
your medicine is what the doctor ordered and
know how to use it. Ask the pharmacist about
your medicine if it looks different than you
expected.
Get the Reports of any Test or Procedure
Ask when and how you will get the results of
tests or procedures. Don’t assume the results
are fine if you do not get them when expected,
be it in person, by phone, or by mail. Call your
doctor and ask for your results. Ask what the
results mean for your care.
Talk to Your Doctor About Best
Hospital for Your Health Needs
Ask your doctor about which hospital has the
best care and results for your condition if you
have more than one hospital to choose from.
Be sure you understand the instructions you
get about follow-up care when you leave the
hospital.
 Chapter 20: Addressing Medical Errors 181
Make Sure You Understand What will
Happen if You Need Surgery
Make sure you, your doctor, and your surgeon
all agree on exactly what will be done during
the operation. Ask your doctor, “Who will
manage my care when I am in the hospital?”
Ask your surgeon:
™™ Exactly what will you be doing?
™™ About how long will it take?
™™ What will happen after the surgery?
™™ How can I expect to feel during recovery?
Tell the surgeon, anesthesiologist, and
nurses about any allergies, bad reaction to
anesthesia, and any medications you are
taking.
Conclusion
The prevalence of medical errors in health
care systems has generated immense interest
in recent years.
Although physicians may be instrument
in providing care to patients, the total patient
care needs support from various “systems”
to minimize medical errors. Indeed, because
the “system” is now the focus of quality, all
members of the healthcare team assume
an even grater role; they must be vigilant
of all aspects of care and note all actual and
potential sources of error, going beyond their
traditional activities and observations.
When serious error occurs, it may
be difficult to ascertain the cause or the
responsible party; but keeping quiet and
hoping the error passes unnoticed is the worst
policy.
Malpractice suits are largely the conse­
quences of depersonalized medical practice.
When practice is time-intensive rather than
technology-intensive, and focused on the
primacy of caring, there need be little worry
about litigation.47
The health care professionals, both in
primary and secondary care, are beginning
to demonstrate a better grasp of reality and
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the issues surrounding medical errors. Errors
should be regarded as an opportunity to learn
that health care should to be patient centered
and not physician centered.
No system is fail-safe unless the patient is
central in the minds of those who administer
drugs or procedures.48
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 21 Medical Records

“Testimony based on recorded facts is given as greater consideration than

testimony dependent on memory”.
“In the present days of medical practice, documentation has become more
and more important; it has now reached a point that if something is not documented,
it is de facto considered not to have happened”.

Introduction Table 21.1  Purposes of the medical record*

• To act as a working document for day-today

Creating and maintaining medical records
(MR) is an integral part of medical practice. The
existence of MR dates back to emperor Ashoka’s
time when individual physician developed
a practice of keeping records. Western world
(USA and European nations) is practising MR
keeping since last 200 years; in our country in
spite of tremendous advances in medical audit,
accreditation and medical insurance systems in
private and public sectors, the MR keeping is still
in nascent stage.1,2
Purpose of Record Keeping
Well-kept MRs are the hallmark of good medical
practice. The MR has many functions, the most
important of which are listed in Table 21.1 MRs
give a clear and accurate picture of the care
and treatment of patients and assist in making
sure they receive the best possible clinical care.
They help doctors to communicate with other
doctors, with other healthcare professionals
and with themselves, and are essential to ensure
that an individual’s assessed needs are met
comprehensively and in good time.
Besides documenting the patient’s history,
physical findings, investigations treatment
and other related data, it shows how clinicians
recording of patient care
• To store a chronological account of the patient’s
life, illnesses, its context and who did what and
to what effect
• To enable the clinician to communicate with him-
or herself
• To aid communication between team members
• To allow continuity of approach in a continuing
illness
• To record any special factors that appear to affect
the patient or the patient’s response to treatment
• To record any factors that might render the
patient more vulnerable to an adverse reaction
to management or treatment
• To record risk assessments to protect the patient
and others
• To record the advice given to general practitioners,
other clinicians and other agencies
• To record the information received from others,
including carers
• To store a record to which the patient may have
access
• To inform medico-legal investigations
• To inform clinical audit, governance and accreditation
• To inform bodies handling complaints and inquiries
• To inform research
• To inform analyses of clinical activity
• To allow contributions to national data-sets,
morbidity registers, etc.
*Adapted from: Scottish Records (1995) Case records: Good
practice group; CRAG good practice statement. Edinburgh.
HMSO. Government publication.

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assessed the problems, what actions they took,
and how the patient responded to their efforts.
An accurate, clear, well organized record
reflects and facilitates:
™™ High standards of clinical care,
™™ Continuity of care,
™™ Better communication and dissemination
of information between
™™ Physicians,
™™ To detect complication at an early stage, and
™™ Documentation of evidence for medico-
legal purpose.
Such records should be accurate, legible­,
comprehensive, up-to-date, and contribute to
easy recall of patient information for continuity
and follow-up of patients, as well as for future
references, such as research.
Standards in Medical
Record-keeping
In the present days, due to heterogeneous
pattern of healthcare, involving plethora of
healthcare providers and institutions has led to
fragmentation of patient medical records, with
no single body responsible for maintaining a
comprehensive record. There is no single model
for a record. In general it may be stated that
the best record is the one that is evaluated and
adapted in response to the needs of individual
and/or inter-professional health care team in the
context of the patient and the local healthcare
regulatory authorities. Thus records may
differ depending on the needs of the patient or
institution. The record must, however, follow
a logical and methodical sequence with clear
objectives. Structuring the record can bring
direct benefits to patients by improving patient
outcomes and doctors’ performance.3-5
Content and Style
There are number of factors that contribute to
effective record keeping. Following guidelines
may be useful:6,7
™™ Accurate patient/family identification data.
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Chapter 21: Medical Records 185
™™ Record accurately date; also include the
time that you are writing notes.
™™ Record all data—both positive and
negative—that contribute directly to your
assessment. They should be as objective
as possible. Hostile or demoralizing
comments should be avoided.
™™ Avoid using personal unexplained
abbreviation. Other physicians must be
able to understand whatever you have
documented. Employ abbreviation and
symbols only if they are commonly used
and understood.
™™ The record must be legible. Not only the
physician who writes the notes should
be able to read, it should be reasonably
comprehensible to others as well. Use of a
dictation service or other documentation
modality assures that the medical records
are legible. Diagrams, explaining certain
physical findings, add greatly to the speed
and ease of communication.
™™ The medical record should accurately
document all evaluations, treatments,
patient compliance problems, follow-
up advice, reasons for omitting specific
tests or treatment protocols, physician
referral notes, all telephone conference with
patients and family members, including
phoned-in prescription and medical advise.
™™ Be sure to document all explanations with
the patient relating to care and treatment
including with respect to informed consent
issues. At every point, should any objection
be raised by the patient and clarification
sought, the patient should be carefully
heard out and necessary information
offered to clear doubts or apprehensions.
However, refusal by the patient for specific
treatment or procedural investigation
should be recorded in the note. In the case
of a minor, consent should be obtained
from the parent or guardian.
™™ Notes once written should not be altered
or erased, or new words added after a lapse
 186  Section 4: The Practice of Family Medicine
of time, as these may indicate defensive
action by the physician in the event of
unexpected eventualities in the course of
patient management.
™™ If new information has to be added, it
should be done in a new note that is dated
as of the time of updated or corrected
information. All notes should be signed in
the order of date, time, and events.
™™ All records should be documented as soon
as possible, before the data fade from
memory.
Practical Ways of Improving
Record-keeping8*
™™ Personally sign all typed letters and entries
on the case record.
™™ Sign and write name in block capitals for
clear identification of handwritten entries.
™™ Date and time all case-record entries.
™™ Give as much thought to case-record
entries as to dictated letters.
™™ Be thorough but concise.
™™ Include periodic summaries in the records of
patients in long-term contact with services.
™™ Be mindful that the quality of the case
record will be assumed to reflect the quality
of the care received.
Weed System: Problem-oriented
Medical Record (Pomr) and Soap
Good MR keeping is part of providing the best
quality of medical care. Ideally, MR should
represent:
™™ A careful documentation of a given
patient’s illness,
™™ The diagnostic and therapeutic approaches
of the physician to that illness,
™™ The day-by-day progress made in dealing
with each aspect of the illness,
*Remember the acronym “Olfactory”, which stands for; Originnal, Legible, Accurate, Complete, Timely,
Objective, rational, and Yours, will help to define a good MR.
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™™ A clear form of communication to
discuss management/prognosis between
physicians, and
™™ A testimonial to the quality of care being
delivered to that patient by the medical
team in charge of his care.
Unfortunately, few of us can say in all honesty
that our records uniformly match the above
description. More commonly, the record consists
of a disorganized collection of facts, comments
and opinions about the case. It’s a common
experience to many physicians to find X-ray
reports in one section, laboratory data in another,
the history and physical findings in a third, the
consultants’ opinions in yet another. Under such
a system (really a non-system), aspects of the
patient’s illness are all too frequently ignored or
forgotten. Also, because MRs do not conform to
any given single format, assessing their accuracy,
completeness and quality of care, i.e. medical
audit, is virtually impossible.
To overcome the state of disorganized
and confusing case notes, Dr. Lawrence
Weed published his proposals of the POMR9
in 1968 and SOAP (Fig. 21.1) in 1969. 10-12
Dr Weed first introduced and has since
popularized the concept of the POMR and
at the same time succinctly pointed out the
deficiencies of our present non-system of
record keeping. Dr Weed proposed that both
patient care and clinical education could be
improved by changing traditional medical
records to a problem-oriented format. The
POMR approach concentrates primarily upon
identifying all of the patient’s problems (not
making diagnoses) and dealing with these
problems in a logical and orderly fashion.
The POMR consists of four essential
elements: data base, problem list, assessment
and analysis, and progress notes (Fig. 21.1).13,14
Data base: It’s the counterpart of conventional
clinical and hospital records consisting of
 Chapter 21: Medical Records 187

Fig. 21.1  Weed system of POMR and SOAP

history and physical examination findings.
It should endeavour to include all the
information which the physician thinks is
necessary and should be designed to meet
individual requirements.
Problem list : It the key to the POMR.
Each problem list should include all of a
patient’s problems: symptoms, diagnoses,
pathophysiological findings, abnormal
physical signs and laboratory investigations.
Psychiatric and social problems are also noted,
as well as relevant past illnesses and any other
factors that may influence patient care.
The problem list can, if necessary, be
changed. If an existing problem is clarified,
or if it is discovered that an entry has been
made in error, then the list can be modified
and changes incorporated. As new problems
arise they are simply added to the problem list.
The problem list is thus a dynamic statement
of the patient’s medical history and allows a
rapid assessment of the situation existing at
any given moment.
Plans: For each problem a goal is decided
and a plan of action prepared. These Initial
plans are written up under individual problem
headings and they are divided logically into
three parts (see below):
1. Diagnosis (Dx)
2. The choice of therapy (Rx), and
3. Patient education (E), which is a statement
of the outcome of counseling, which has
taken place with patients about their illness
and subsequent management.
Progress Notes
These are follow-up notes which are recorded
under four major subheadings, i.e. “SOAP”*:

*Guidelines and Examples on the SOAP Format for Chart Notes. Available at the web site—
http://www.hptn.org/MOP%20NEW%20CD/PDFs%20Complete/Appendices%20and%20Glossary/
Appendix2SOAP%20Guidelines%20and%20Examples.pdf (accessed on 06-11-2011).

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 188  Section 4: The Practice of Family Medicine
1. Subjective data—related to the progress of
the patient’s symptoms,
2. Objective data—findings on physical
examination and the results of investi­
gations,
3. Assessment and analysis—related to
physician’s outcomes of the illness and
prognosis, and
4. Plan for future action—additional data
collection, lab work-up, interventions,
referral to other physicians, etc.
Weed pointed out that the features
with which patients present to physicians
could, by the application of their inquiring
and experienced mind, be designated as
“problems”. These might be a symptom, a sign,
an abnormal laboratory or imaging finding, a
psychosocial factor or a previously diagnosed
disorder. The list of such problems vary in their
emphasis and significance according to various
factors, including physicians’ specialties, and
the perceptions of their appropriate roles in
the care of the patient. Such a list of problems
is further grouped into two, namely “active
problems”, which need prompt evaluation
and “inactive (or resolved) problems”, which
physicians need to be aware of. To identify
all the problems, patient’s history, physical
Table 21.2  Weed system
examination, and investigations have to be
completed which form the initial “data base”
for further clinical activity.
In the Weed system, two columns are used:
active problems go to the left, inactive ones to
the right15 (Table 21.2).
The list illustrated here includes problems
that need some attention now (such as the
headaches), and others needing further
observation in future (such as the hypertension
and obesity). For each “active problem”, an
initial management “plan” is developed which
is written in the records in the form of “SOAP”
model.
Physician’s “plan”
S = Subjective data: This is compiled from
history, symptoms
of headache, family
history, etc.
O = Objective data: This includes doctor’s
physical findings and
tests reports.
A = Assessment/
Analysis: The doctor’s under­
standing of the
problems in terms of
its pathophysiology.

Name—Ms. X  Age—48yrs  Sex—F

Date problem Sl. no. Active problems Inactive problems
Entered
06.05.04 1 Migraine Headaches —
06.05.04 2 — UTI
06.05.04 3 Sulfa allergy —
06.05.04 4 Stress in family —
06.05.04 5 Low back pain —
06.05.04 6 Borderline hypertension —
BP-140/90
Diet-high in calories; low —
in calcium.
06.05.04 7 Obese-BMI-31.5
Obesity
06.05.04 8 — Family h/o migraine
06.05.04 9 — Diabetic profile—normal
06.05.04 10 — Fundus—normal

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P = Plan— Goals, action, advise,
etc., which includes
Diagnostic (Dx),
Therapeutic (Rx) and
 Education (E) in
the context of above
mentioned data.
For Example: In the illustration above, the
active problems of this patient (Ms. X) may be
documented as below:
1. Plan for migraine headaches:
Diagnostic (Dx) — observe the patient and
note any precipitating factors.
Therapeutic (Rx) — Continue paracetamol
as needed.
Education (E) — Nature of migraine
discussed, advised to maintain headache
diary.
2. Plan for borderline hypertension:
Diagnostic (Dx) — Monitor BP periodically,
and urinalysis.
Therapeutic (Rx) — None now, consider
diet advice.
Education (E) — Importance of BP
monitoring explained.
A month later, when Ms. X returned for a
second visit, her follow-up or progress notes
could be written as follows:
1. Migraine headaches
Subjective (S)—Has had only 2 headaches,
mild, without associated symptoms,
no longer worried about them, no
precipitating factors detected.
Objective (O)—Not reexamined.
Assessment (A)—Improved.
Plan (P)—Continue paracetamol as
prescribed; return as needed.
2 Borderline hypertension.
Subjective (S)—None.
Objective (O)—BP – 145/06 – Right arm,
lying; urinalysis—normal.
Ass essment (A)—Is olate d systole,
hypertension.
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Chapter 21: Medical Records 189
Plan (P)—Follow-up BP recording in 3
months.
Thus, to begin with, a problem list is
prepared after completing the history, physical
examination and data from investigation,
etc. These are assigned as active/inactive
problems. For each active problem, a tentative
management plan in made out in term of its
Dx, Rx, and E. At subsequent visits or those
responsible for changing the management
plan, use the mnemonic SOAP to record their
findings and reasons for doing so. Discharge
summaries and letters to colleagues use the
same format.
These proposals by Weeds were designed
to improve the structure of medical records
and to encourage a logical thought process
and approach to record keeping, aiming to
generate less narrative and clearer records
for community information about a patient to
another clinical professional.
Weed System and Medical Audit
The problem oriented approach offers several
important clinical and educational benefits,
particularly its ability to audit the quality of
medical care. Weed audit is a key factor in the
training of both undergraduates and hospital
junior staff and has also been recommended
for the continuing education of both the general
practitioner and the hospital consultant.16,17
The concept of POMRs facilitates better care
of patients by supporting continuity of care,
removing redundant and confusing information,
and enabling easy overview of and access to its
content.18 Predictably, the POMR will avoid
problems associated with malpractice litigation;
conform to regulations of third-party payers,
and facilitate practice analyses and quality
assessment, i.e. through computer-assisted
tracking of patient care based on problems
and not just treatment rendered. In contrast to
existing computerized patient record systems,
which merely offer static functionality for storage
 190  Section 4: The Practice of Family Medicine
and presentation, a helpful patient record
system is a problem-oriented, knowledge-
based system which provides the clinician with
situation-specific information from the patient
record, relevant to the activity within the patient
care process.19 As many practices today focus on
a “patient-centered” approach to practice, the
problem-oriented record clearly supports such
a philosophy in its completeness of managing
patient care information.20
Limitations of the POMR
One major objection to Weed system is with
respect to its complete collection of data base
which is too cumbersome and lengthy progress
notes, resulting in its impracticable application
for the busy doctors in general practice or in
outpatient departments. Some studies suggest
using the POMR only when the patient is
assessed for the first time or when information
is passed from one team of doctors to another,
while others observe that POMR is primarily
focused on the individual, and thus has serious
deficiencies for the family-oriented physician.21, 22
From Soap to “Snocamp”
The Weed’s methodology was widely adopted
in the USA and was also in widespread use
throughout the UK in general practice. 23
However, with the intrusion of third–party
audits, malpractice suits, medical guidelines,
health insurance codes, and many other
administrative and legal procedures in the
practice of medicine, a need was felt to expand
the traditional SOAP model.24
As a defense against new mediclaim
policies and increased risk of physician
practice audits, an improved method of
documentation, without sacrificing ease of
use, efficiency, and cost-effectiveness, a new
SNOCAMP model was developed in early
*E/M Coding or E&M Coding is a medical billing process that practicing doctors in the United States
must use to be reimbursed by Medicare, Medicaid programs, or private insurance for patient encounters.
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1992 and first published in a guidebook on
documentation in 1993.25,26
SNOCAMP is a medical records format (Table
21.3) that includes the same four elements of
SOAP format — Subject, Objective, Assessment
and Plan of treatment — with the addition of:
1. Nature of patient’s presenting problems
(low/medium/high/severity)
2. Counseling
3. Medical Decision Making (high/medium/
low complexity)
Subjective (S): As in the SOAP format, “subjective”
is the first component in the SNOCAMP format.
In this portion, patient’s chief complaints,
history of present illness, past and family history,
and system review are recorded.
Nature of the Presenting problems (N or NPP):
This is the second component of SNOCAMP.
It describes the complexity or severity of the
patient’s chief complaints, which can be a
disease, any illness, injury, symptom, sign,
lab reports, or other reasons for the encounter.
The physician’s opinion of the NPP is a vital
component of documentation, as it plays a
critical role in the management plan of the
patient and assigning appropriate “evaluation
and management” (E&M)* service code for
mediclaim purposes. The NPP component
Table 21.3  From SOAP to SNOCAMP
From SOAP To SNOCAMP
Subjective
Subjective
Nature of Illness (high/medium/low
severity)
Objective
Objective
Counselling
Assessment Assessment
Medical Decision Making (high/
medium/low complexity)
Plan Plan

is described in terms of one of fine possible
levels: minimal, self-limited or minor, low
severity, moderate severity, and high severity.
When the NPP falls between two descriptive
levels, e.g. low to moderate, it can be stated as
such or can be described as the more complex
of the two. The word “potential” can be added
to reinforce physician’s concern regarding the
potential severity of the presenting complaint
(e. g. pericardial chest pain could easily be
described as “potential high severity” even
if subsequent investigation revealed that the
patient had costochondritis).
Objective (O): This is the third component
and includes the vital signs and physical
examination findings. Results of diagnostic
tests are recorded in this portion of the
documentation.
Counseling and/or Coordination of care (C):
The fourth component details any discussion
the physician may have had with a patient
and/or family concerning the physician’s
clinical impression, prognosis, risk and
benefits of management options, follow-up
instructions, importance of compliance with
treatment, risk factor reduction, and patient
and/or family education.
Assessment (A): The fifth portion of the
document consists of physician’s personal
analysis of patient’s problems, based on the
data obtained thus for. It should show the
analysis of differential diagnosis, management,
treatment options and likely complications.
Medical decision making (M): The sixth
component of medical decision-making
includes the analysis of complex issues
involved in making a diagnosis or selecting
a management options. Determination of
the appropriate level of medical decision
making comprises multiple factors, which
include differential diagnosis or management
options, risks of complications and morbidity
or mortality. It is based on information
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Chapter 21: Medical Records 191
recorded in the assessment, counseling, and
management plans of the medical record.
Plan (P): The final section of the SNOCAMP
format involves the plan of treatment or
treatment options the physician will utilize
in managing the patient’s problems. It also
includes the rationale for recommending or
changing a previously designated therapy or
ordering of diagnostic tests, unless already
discussed in the counseling or the assessment
sections.
The main advantages of SNOCAMP format
are two fold: first, it allows the physician
to present documentation efficiently and
effectively in style that will enhance the
selection of an appropriate “evaluation
and management” service code level in the
context of mediclaim policies, and secondly,
the format also has the potential to increase
audit protection and defend against possible
litigation (Table 21.4).
Medical Council of India (MCI)—
Importance of Medical Records27
It is the responsibility of every physician to
properly maintain; in accordance with the
standard proforma provided (as laid down by
the MCI) all medical records relating to his/her
outdoor/indoor patients for a period of 3 years
form the date that the treatment was started.
The phrase “medical records” takes
within its fold the following documents which
normally form part of the medical service
rendered by the medical practitioner. Marginal
difference may occur depending upon facts
and circumstances of a given doctor patient
relationship.
a. ‘Informed consent’ form (i.e. valid and free
written consent for medical management
of illness, which has been explained to
the patient, and given voluntarily by the
patient in a healthy state of mind).
b. Diagnostic records.
c. Referral and prescription ships.
 192  Section 4: The Practice of Family Medicine
Table 21.4  Example of SNOCAMP
S Patient, 45 years/Male, garage mechanic,
smoker, c/o retrosternal chest discomfort,
radiation of pain are arms, shoulders,
precipitated by exertion, emotional stress, lasts
for approximately 1–5 minutes and relieved by
rest; wife 40 years? Ca. breast and DUB.
N High severity; NYHA classification – class 3
O No skin xanthomas, BP-148/96, pulse-82/mit,
regular, peripheral pulses – normal, cardia – S1,
S2 normal,? mitral regurgitation; other systems
– normal
C Discussed diagnostic possibilities; risks and
management options with patient
A 1 – Angina pectoris/unstable angina
2 – Mitral valve prolapse
M Rest, sublingual nitroglycerine, aspirin, beta-
blocker
P 1 – Resting ECG; ? TMT; 2D echocardiogram;
lipid and metabolic profile
2 – Coronary angiogram
3 – Consider coronary revascularization and/or
medical management
4 – Prevention – diet/exercise advice; medi­
cationsanti-platelets, beta-blockers, statins;
periodic follow-up
d. Patient case sheet.
e. Operation notes.
f. Certificates issued.
g. Discharge summary and/or “Discharge
against medical advice” details
h. Death summary where applicable.
i. All medical receipts serially numbered.
In case patients or attendants authorized
by them, or concerned legal authorities make
a request for medical records, it should be duly
acknowledged and the relevant documents
must be made available within a period of 72
hours.
Courts generally believe in doctor’s records
if the records apparently appear to be genuine.
However attempts should not be made to
“create” records afterwards.
*A medicolegal case is a case of injury/illness where the attending doctor, after eliciting history and
examining the patient, thinks that some investigation by law enforcement agencies is essential to establish
and fix responsibility for the case in accordance with the law of the land.
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Patients if treated “free” are not “consumers”
and are not entitled for compensation under
Consumer Protection Act. Therefore, if patient
is treated free it should be clearly mentioned.
Some doctors do not keep records of ‘free’
cases. Since free treatment is an important
defense, records should be maintained even
in case of free treatment.
Medicolegal Records
Doctors encounter patients suffering
from illnesses or injuries arising out of
circumstances, which have legal implications,
i.e. a medical case with legal implications or a
legal case requiring medical expertise. Such
cases are generally termed as “medicolegal
cases (MLC).”*
In 1995, the Honourable Supreme Court
of India gave the decision that all doctors,
whether in government service or private
practice, come under the purview of the
Consumer Protection Act (1986).28 Courts are
looking with increasing favor on the patients’
interest in the content of their records—a
phenomenon which is closely linked to the
nationwide trend in favor of the patients’ right
to know and determine their own physical
destiny. For all these reasons, medical records
no longer serve exclusively as the physician’s
private aid; medical records are increasingly
becoming legal documents as well.
Medical records are also important in
workman’s compensation cases, insurance
claims, and even in physician disciplinary
hearings—hearings where physicians’ right
to practise may be affected or where their
integrity or reputation may be called into
question, as well as their collection of bills.
Further, in creating and maintaining patient
records, physicians and hospitals have several
legal duties, including the duty to do so

adequately, to safeguard the records’ physical
existence, and to prevent such use of the
records as would violate the patient’s right
to confidentiality. Thus, medical records
have become an important aspect of written
evidence.
In the Criminal Procedure Code of India
(CrPC), following categories of cases are
designated and dealt with as MLCs, and as
such the doctor is “duty-bound” to intimate
to the police regarding such cases:
™™ Sudden death with unknown cause.
™™ Cases brought dead with improper history
creating suspicion of an offence.
™™ Death caused by homicide, suicide
or infanticide, i.e. death by violent or
unnatural means.
™™ Death caused by use of a vehicle in the
street, public road or private place.
™™ Death caused by rash and negligent act.
™™ Death occurring in jail or any place of
detention.
™™ Criminal abortions.
™™ Hurt, including grievous hurts.
™™ Hurt caused voluntarily by shooting,
stabbing, cutting, or any instrument which
is used as weapon of offence, or by means
of fire (burns), corrosive substance, or
poison, or explosive substance.
™™ Unnatural sexual offences, i.e. sodomy,
bestiality, etc.
™™ Intoxication of alcohol in those states
where prohibition is in force.
™™ All cases of suspected or evident poisoning.
™™ Cases referred from court or otherwise for
age estimation.
™™ Cases of compensation.
Apart from the cases listed above, any case
having direct or indirect legal bearing and not
falling under the above categories but has
legal implications, can become a MLC at any
stage. Further, in all other cases, where there
is ambiguity, improper history, history not
correlating with the clinical data, it is better
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Chapter 21: Medical Records 193
for the doctor to inform the appropriate
investigating authority to decide whether or
not the case is a MLC. There should not be
any unnecessary delay in doing so. A case may
be registered as an MLC even if it is brought
several days after the incident.
The records of medicolegal evidence
should be stored in secured place and a
register should be maintained of its movement.
No unauthorized person should have access to
this record and no copy should be given to any
one, except to the legal authorities.
Conclusion
Medical records speak louder than words.
Clear, complete, and adequate medical
records, including negative findings, prognosis,
progress notes and plan of treatment are
doctors’ best friend and best defense in the
court, if maintained properly and honestly.
MLCs pose no problem if one uses proper
caution and due care and attention, while
dealing with them. Proper documentation,
timely information, a methodical and
thorough examination — including all relevant
investigations and referrals, etc, are all that
are necessary to see such cases through,
successfully.
Although the method of POMR keeping
is time consuming and may not ensure
excellence in medical care, it does serve as
a tool without which excellence would be
difficult to achieve and virtually impossible to
identify.
References
1. Daga Surendra, et al. Medical record keeping
– Are we prepared? JIMA. 2008;106(3):145.
2. Menon Girish et al. Research involving medical
records review: an Indian perspective Indian J
Med Ethics. 2006;3(2).
3. Mann R, et al. Standards in medical record
keeping. Clin Med. 2003;3(4):329–32. [PMID:
12938746: Abstract].
 194  Section 4: The Practice of Family Medicine
4. Chamisa I, et al. Setting the records straight—a
prospective audit of the quality of case notes
in a surgical department. S Afr J Surg. 2007;
45(3):92, 94–5. [PMID: 17892187: Abstract].
5. Pourasghar F, et al. What they fill in today,
may not be useful tomorrow: lessons learned
from studying Medical Records at the Women
hospital in Tabriz, Iran. BMC Public Health.
2008;8:139. [PMID: 18439311: Free PMC
Article].
6. Alan Lambert. Red flags in medical record
documentation; your records can be your best
friend or your worst enemy—The Legal Corner.
Podiatry Management, 2004.
7. Guidelines for records and record keeping.
Nursing midwifery council. Guidence 02.04.
8. Pullen Ian et al. Improving standards in clinical
record-keeping; Advances in Psychiatric
Treatment. 2006;12:280–86.
9. We b s i t e — h t t p : / / m e d i c a l - d i c t i o n a r y .
thefreedictionary.com/Problem-Oriented +
Medical + record
10. Weed LL: Medical records that guide and teach.
1; Eng J Med. 1968;278:593–600 and 652-657.
11. Weed LL. Medical records, Medical education,
and primary care: The problem – oriented
record as a basic tool. Cleveland, OH: Case
Western Reserve Univ, 1969.
12. NHS Information Authority: POMR and SOAP
Briefing paper. 1999.
13. Gardner LB. The Problem Oriented Record
in Critical Care Medicine. Chest, 1972;62:
63S-69S.
14. Mcintyre Neil. The Problem Oriented Medical
Record BMJ, 1973;2:598–600.
15. Barbara Bates. Physical exam and history taking:
The patients record. 4th Ed, 1974;623–24.
16. Barresi BJ, et al. Implementation of the
problem-oriented system in an optometric
teaching clinic. Am J Optom Physiol Opt, 1978;
55(11):765–70.[PMID: 313158: Abstract].
17. Ingber JS, et al. The problem-oriented record:
clinical application in a teaching hospital.
mebooksfree.com
J Dent Educ, 1975;39(7):472–82. [PMID:
1080162: Abstract].
18. Bayegan E, et al. A problem-oriented,
knowledge-based patient record system.
Stud Health Technol Inform, 2002;90:272–6.
[PMID: 15460701: Abstract].
19. Bayegan E, et al. The helpful patient record
system: problem oriented and knowledge
based. Proc AMIA Symp, 2002:36–40.
[PMID:12463782: Free PMC Article].
20. Valenza JA. Medical risk report: improving
patient management and record keeping
through a problem-oriented approach. J Gt
Houst Dent Soc, 1994;65(9):46–8; quiz 49.
[PMID: 9584737: Abstract].
21. Antoniou AG, et al. Problem orientated
medical records--all or none? Med Educ, 1979;
13(3):217–8. [PMID: 314561: Abstract].
22. Grace NT, Et al. The Fam Pract, 1977;4(1):91–8.
[PMID: 299885: Abstract].
23. Margolis CZ. Problem-oriented record. A
critical review. Paediatrician, 1979;8(3):152–62.
[PMID: 315045: Abstract].
24. Larimore,W L et al. SOAP to SNOCAMP:
improving the medical record format. The
Journal of family practice; Vol: 41, Issue: 1995.
25. Walter LL. SOAP to SNOCAMP: Improving
medical record format. Dowden health Media.
Inc. 1995.
26. Jordan E.V St Anthony’s guide to E/M coding
and documentation. 1st Ed. Reston, Va: St.
Anthony Publishing, 1994.
27. Purnapatre, et al. Doctor and the Consumer
Protection Act: Part II. Maharastra Law Agency,
Nashik, 1994.
28. Consumer Protection Act 1986 & Its Medical
Profession related Provisions After The
Judgment Honorable Supreme Court of
India dated 13-11-95. Web site - http://www.
medindia.net/doctors/cpa/CPA1-12.asp.
Accessed on - 02-11-2011.
 22 The Difficult Patient

“Despite all the adversities and all the stumbling blocks put in our way, it seems
that we must revert back to the centuries-old advice that Plato espoused, that modern philosophers
promote, and that consensus medical committees tell us is still the corner­stone of medical care, namely,
the an­swer to handling the difficult patient is nothing more than communica­tion, loyalty, and a strong
commit­ment to the power of the doctor-pa­tient relationship.”
“Your most loyal patients will always be those who had a problem that you solved to
their satisfaction rather than patients who never had a problem.”

Introduction This study concludes that, “no consistent

Physicians in their practice encounter patients
who are unique in their combination of age,
health, personalities, experience, up bringing,
faith, reasoning abilities, and many other facets
of individuality. Patients can be demanding,
annoying, unrealistic, loud and objectionable.
They can be pleasant, easygoing, intelligent,
accommodating and knowledgeable. They
can also be timid, questioning, unprepared,
lacking knowledge, and uncertain about what
they want or need. However, patients get
good medical care on most of the occasions,
no matter how they act or behave. This
observation has been supported in a study
published in the Annals of Internal Medicine,
participating 422 family practitioners and
general internists, and 1795 of their adult
patients with diabetes, hypertension, or heart
failure, to assess the relationship among:
1. Adverse primary care work conditions (e.g.
time pressure, chaotic work place),
2. Adverse physician reactions (e.g. stress,
burnout, and intent to leave), and
3. Patient care.
associations were found between adverse
work conditions and the quality of patient
care, and no associations were seen between
adverse physician reactions and the quality
of patient care.” 1 It is apparent that in the
present rapidly changing healthcare system
with pressure of time, achievements, income,
and other responsibilities in hasty and
disorganized work conditions providing
quality service is a continuing challenge; and
indeed, providing great service to ‘difficult’
patients is an exceptional challenge. It is,
therefore, important to learn how to identify
and pleasantly meet the real needs of the
challenging patients. This involves learning
proven strategies for meeting the needs of
difficult patients while maintaining peace and
harmony of physician’s practice.
Dealing with difficult patients does not
need all the time and energy, not if the
physician understands how to communicate
successfully with them. Learning how to get
the best of the medical concerns and patient’s
hardships with appropriate use of patient-

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 196  Section 4: The Practice of Family Medicine
doctor communication skills, and an effort
to improve relations with patients through
empathy, tolerance and non-judgmental
listening, physicians will be more successful
than ever. It’s important to understand that
the objective of identifying ‘difficult’ patient
is not to label that patient, but to recognize
the need for special skills to manage such
patients.“Several factors may assist the 21st
century physician in managing the ‘hateful
patient’ in an empathic manner and in making
some sense of why the patient has resorted
to negative response patterns. Ultimately, a
failure to consider these issues will result in
poorer medical care and, no less important,
reduced satisfaction of both patients and
doctors”.2
Terminology and Incidence
(Table 22.1)
The term ‘difficult’ often refers to a legendary
and well-recognized group of patients lacking
the cooperation between patients and
physicians. Although patients seek help and
care, they do not readily accept what is offered
resulting in physicians experiencing difficulty
forming a normal therapeutic relationship.
Table 22.1  Characteristics of the difficult patient
•  Frequent consultations/visits (fat-folder patients)
•  Multiple (unexplained) physical symptoms
•  Undue concern about minor symptoms
•  Unrealistic expectations of cure
•  Behavior—aggressive, abusive, demanding,
hostile
•  Scant regard to physician-patient relationship
•  Personality disorder—either undiagnosed, or
borderline present
•  Won't or can't get better—sick role issues
•  May have chronic medical disorders or social
disabilities
•  Somatization disorders
•  Chronic pain syndromes present
•  Alcohol, drug addiction
•  Non-compliance (including treatment)
•  Manipulative
•  Legal/compensation problems
•  Litigious
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Different terms have been used to describe
“difficult” patients. They may be described by
their personality which is often aggressive,
abusive, rude and demanding. At the most
superficial level, difficult patients are defined
by the feelings physicians have when they
work with them. They arouse helplessness
and exasperation leading to frustration,
uncertainty, anger and a feeling of being
manipulated or controlled by the patient.3
Some call them “heartsink patients”. In
the United Kingdom, Tom O’Dowd4 initiated
discussion of such patients in the BMJ in
1988, coining the term “heartsink” to describe
intuitive feelings of impending doom or
helplessness when certain names appear
in the appointment book. Ellis, a general
practitioner, coined the phrase “dysphoria”
to define “the feelings felt in the pit of your
stomach when their names are seen on the
morning’s appointment list.” 5 Heartsink
patients exasperate, defeat and overwhelm
their doctors by their behavior. Importantly,
he described how they were a source of stress,
as they aroused negative feelings and so
made some doctors feel unprofessional and
frustrated. Many of these patients have a “‘thick
file” in the doctor’s office and are informally
called as “thick-file or fat-folder patients”.6
Difficult patients include those who are
medically challenging, interpersonally difficult,
psychiatrically ill, or lacking in social support.
The overall impression from the literature is
that difficult patients consume considerable
time and resources, receive many unnecessary
investigations, can be litigious, and can cause
their doctors considerable anguish. Such
patients make up 15–30% of primary care
practice populations.7 It is generally observed
that the incidence of difficult patients is more in
women who are widowed or divorced; however,
this ratio equals both in women and men as age
advances. The average age of their presentation
is over 50 years, with lower educational status,
have higher scores of anxiety and depression,

and lower perceived quality of life. They are
more likely to have chronic diseases.8,9 However,
the incidence of difficult patients decreases with
experienced doctors who perceive less difficult
patients as they learn to acknowledge greater
diversity of behaviors in their patients.
Characterizing the Difficult Patient
In a seminal article, Groves et al10,11 characterize
four stereotypical “hateful patients” (i.e.
patients whom most physicians dread or get
upset) according to their manner of interacting
with physicians:
Dependent Clingers
“While thanking the doctors for all they have
done, patients are desperate for reassurance
and visit them repeatedly with an array of
symptoms.”
They prolong the consultation and are
dependent on physicians all the time; they keep
coming back again and again for minor illnesses/
complaints for reassurance or a ‘pill for an ill’, ask
for repeated prescriptions or favors. They flatter
the doctor by excessive praise; e.g. “I’m sorry
to trouble you again doctor but you are such a
careful doctor …”; “Doc, you are great…your pills
worked like magic, thanks…and came to see you
just in case…!”. Their care involves protracted and
intense physician-patient relationship — they are
“doctor dependent.”
The best strategy with dependent clingers,
according to Groves is — early identification
of the problem, be consistent and firm, control
your own feelings, and deal tactfully but firmly
to patient’s problems without unduly prolonging
the consultation.
How should we Handle them?
™™ Set boundaries and limits, i.e. give fixed
appointments and adhere to the time
allotted, or alternatively, set a professional
fee for every time-bound consultation.
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Chapter 22: The Difficult Patient 197
™™ Consider delayed response, i.e. make them
wait before you see them; stop them from
feeling so special.
™™ Encourage self help behavior. Help them to
form their own coping strategies. Get them
to accept ownership of the problem, i.e. it’s
their problem, not yours!
™™ Check yourself, i.e. stop carrying your
views or feelings into the subsequent
consultations.
Entitled Demanders
“These patients view doctors as a barrier to
receiving services and complain when every
request is not met.”
They seek attention through intimid­
ation, devaluation, and inducing guilt in
the physician. These patients always want
something and they want it now; e.g. they
may demand investigation, treatment or
even referral! They get their way by instilling
a sense of fear, intimidation, and guilt, or by
devaluing the doctor (unlike the dependant
clinger who uses flattery to get his/her way),
and often threaten the doctor with legal
action if their request is not honoured, e.g.
“I want some antibiotics for my chest cold…
only antibiotics will work…if you don’t and if
anything happens, be it on your head.” They
may try to establish control over a physician
by, e.g., withholding payment or instituting
litigation. Entitled demanders evoke fear and
attack upon their entitlement.
With these patients Grove recommends
supporting the entitlement (rights, priorities,
etc.), but trying to redirect it along the lines of
the treatment plan.
How should We Handle them?
™™ Try to be pleasant, helpful, and establish
a rapport.
™™ Negotiate a treatment plan that is indicated
rather than giving way to the wishes of the
patient.
 198  Section 4: The Practice of Family Medicine
™™ Beware of your ethical and legal safety—
better to be wise than sorry!
Manipulative Help-rejecters
“Patients need abundant emotional support
and visit often to tell physicians the therapy
did not work.”
They are not hostile and they do not claim
to deserve treatment. On the contrary, they
believe that no treatment whatsoever will help
them. They derive satisfaction from repeatedly
reporting to physicians that their treatment
has failed, but despite failed therapy, they still
keep coming back to the same physician. If one
symptom disappears, another invariably takes
place. Even if a symptom/ailment has been
successfully resolved, it will only be replaced
by another! These patients do not seek relief
of symptoms, but rather an interminable
relationship with the physicians and also make
them feel guilty and inadequate.
The best strategy with these patients,
Grove claims, is to share their pessimism,
but at the same time try to ally their fears by
counseling and scheduling regular follow-up
appointments.
How should We Handle them?
™™ Set boundaries and limits, i.e. identify what
the patient wants and set limits on their
expectations.
™™ Share the responsibility with others,
e.g. delegate to nurses, other doctors,
counsellors, psychologist, psychiatry, etc.
™™ May be even agree with their views, e.g.
‘OK, you’re right, that probably won’t help!
Let’s try another way.’
4. Self-destructive deniers: “Although patients
possibly suffering from serious disease,
they make no alteration in lifestyle. It seems
that patient’s aim is to defeat physician’s
attempts to preserve their lives.”
They unconsciously engage in behavior
that is likely to be fatal. They derive satisfaction
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from their own self-destruction and defy
physician’s attempts to preserve their lives.
Often, they have life-threatening illness, e.g.
ischemic heart disease, COPD; but in addition,
they indulge in injurious habits such as
tobacco smoking that worsen their condition
which they are not prepared to give up; they
want a miracle cure from the doctor instead.
They are not prepared to alter their lifestyle!
These patients abandon all hope and become
profoundly dependent … ‘only you can help
me doctor…!’
Grove advices not to abandon these
patients, but instead to work with them
compassionately and diligently, just as one do
with patients who have terminal malignancy.
How should We Handle them?
™™ Explore their health belief system and get
them to try and change it if possible (ref.
the CALMER approach below).
™™ Encourage self help behavior.
™™ Get them to accept ownership of the
problem.
™™ A psychiatric consultation to determine any
treatable depression may be considered.
Who is at Fault
A “difficult” patient can be the result of
personal flaws in a physician or failure in
the physician-patient-relationship (Table
22.2). Physicians have different personalities
and personal characteristics. Hence it’s not
surprising that different physicians have
different sets of difficult patients. Patients
considered “difficult” by one physician
might not be thought “difficult” by another.12
Labeling and thus dismissing difficult patient
is easy, but not helpful. Instead, it is more
helpful to consider that the “relationships”
may be difficult rather than the patients; or to
put it another way—“there is no such thing as
a difficul patient; simply a failure in the doctor-
patient relationship.13

Problems in the Physician
Physicians’ own attitude and behaviour can
generate difficult patients (ref. physician’s
factors in Table 22.2). Besides, the survey of
Sheffield GPs conducted by Mathers et al
(1996) found that physicians who were more
likely to label patients as difficult were those
that were:
™™ Greater perceived workload,
™™ Low job satisfaction,
™™ Lacking in counseling/communication
skills, and
™™ Lacking in appropriate/post graduate
qualifications.
Hegemonic education: The present medical
education teaches a “biomedical-model”2 of
diseases which focuses on physical processes
that affect health such as physiology and
pathology of diseases. There is a sequence
from symptoms to objective data, diagnosis,
treatment, and then to care. However, this
dominant biomedical model cannot fully
explain many forms of illness because it
Table 22.2  Difficult patient: Causes for failure in
physician-patient relationship
1. Situational factors:
• Time pressure
• Language barrier
• Lack of privacy
2. Physician factors:
• Overwork
• Failing to take comprehensive view of illness
• Failure to recognize psychosocial determinants
• Poor communication skills
• Being overly critical or judgmental
• Having a defensive personality
• Low level of experience
3. Patient factors:
• Hostile, demanding, dissatisfied behavior
• Manipulative behavior
• Doctor shopping
• Failure to pay bills
• Difficult to communicate
• Lack of literacy
• Patient non-compliance
• Seductive, sexually or otherwise
• Drug-alcohol abuse
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Chapter 22: The Difficult Patient 199
does not take social or psychological factors
into account.14 Many patients present with
symptoms that are not attributable to any
underlying pathology or disease, e.g. functional
somatic syndromes and personality disorders
which are most prevalent in difficult’ patients.
Physicians who are educated in such “disease-
centerd” system sometimes feel frustrated when
the biological patho-physiologic sequence
breaks down, as it surely will when dealing
with ‘difficult’ patients. The physician may
then order additional diagnostic tests, or
prescribe different drugs in the hope of curing
the aliment, or respond to a perceived failure
by becoming angry and demanding. The
patient is viewed as a “problem” because the
physician has not taken a comprehensive view
of psychological and psychosocial determinants
that ails majority of ‘difficult’ patients.
Where a biomedical approach is clearly
failing, the model has been widened to be
more inclusive of the patient’s “psychosocial
model”.11 This in turn leads to the development
of “patient-centered” clinical methods (i.e. the
patient as an individual, emotional reaction to
illness, the family, the effect of relationships,
work and leisure, lifestyle, the environment)
in which physicians shift their approach to
empower patients in healthcare delivery
system by concentrating more on patients
perception of illness (what is the patient trying
to tell me?) rather than their own.
Further, physicians who are new to practice
lack sufficient ongoing contact with patients
and increasing time pressure make it ever
more difficult to establish the rapport that’s
essential to get to know patients as individuals.
In such circumstances physicians are most
likely to perceive patients as “problems
and develop feelings of inadequacy and
despondency when required to address
multiple vague symptoms.”15,16 However, as
they gain experience and confidence, they
become more tolerant and adopt a practice
style suitable to individual needs.
 200  Section 4: The Practice of Family Medicine
Problems in the Physician-
Patient Relationship
A crucial aspect of treating a difficult patient
is the cultivation of a clear awareness within
the physician of what is happening to the
physician-patient relationship. Physicians can
then direct their efforts toward developing a
structure for the relationship that will allow
for efficient medical management and will be
supportive of the patient’s emotional needs.
Some important causes of difficult patients
in the context of physician-patient relationship
(Table 22.2) include not communicating well
with a patient, not finding what a patient wants,
not recognizing how a patient copes with his
disease, and not understanding the meaning
of illness for a patient. Any of these can lead
to counter productive, negative, or non-
compliant behavior on the part of a patient. But
these failings are the fault of the physician. They
should not be obscured by blaming patients
for their personality or for some problem
they allegedly have. Rather, the breakdown
in the physician-patient relationship should
be identified and remedied.9 In addition, a
physician’s failure to carefully listen, show
empathy, or establish trust may result in an
inadequate understanding of the patient’s
history and illness.17
Physicians are not only responsible for their
own behavior with patients but also for their
employees. Employees who are inconsiderate
of patients’ can cause many difficulties in the
physician-patient relationship, e.g. denying or
withholding medical bills, or reimbursement
of bills, or delay in referral. It is important that
physicians’ understand and work-out their
employees’ healthcare plans and ideas. They
hear their patients’ comments and complaints
and can be a storehouse of suggestions for
improving services specifically tailored
to manage difficult patients so that these
patients are treated in a pleasant and efficient
atmosphere.
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Disorders to Consider18
In an Israeli qualitative research study
conducted in the setting of family practice,19
the contributory disorders the difficult patient
is likely to suffer from were:
1. Behavioral problems, e.g. violent, aggressive,
verbally rude, lying, manipulative,
demanding, seeking secondary gain and
exploitative of the doctor, unresolved
repeated complaints, and non-cooperation.
To these group alcoholics, drug addicts may
be included because of they are associated
with violent behavior.
2. Psychiatric disorders, e.g. depression,
anxiety, panic, hypochondriasis, and
somatoform disorders.
Depressed patients often seek a medical
explanation for chest pain, backache,
headache, fatigue, low energy or libido, as well
as problems with eating, weight, and sleeping.
Anxiety can present as hypochondriasis,
which prompts patients to express intense
concern about relatively minor or transient
symptoms.
Patients with somatoform disorders, who
are unaware of their emotional distress, channel
their stress into a wide range of clinically
inexplicable multiple and chronic unexplained
physical symptoms that may occur in different
sites simultaneously, e.g. gastrointestinal,
sexual, and neurological symptoms, including
‘disease phobia’, i.e. the fear that they may
acquire those identified disease.
Survivors of abuse, particularly childhood
sexual abuse, are more likely than others to
seek frequent medical attention as adult.20
Patients with a hysterical personality,
characterized by their pervasive pattern of
excessive emotionality and attention seeking
behavior, are experienced as difficult patients
by some physicians.
Malingering constitute another
category. These so called disability seekers
may be consciously seeking a high level of

unproductive medical care in order to validate
compensation claims.
Strategy to Handle Difficult
Patients (Table 22.3)
Even the “hardest-to-please” patients can
become loyal patients when problems are
handled courteously. Physicians can develop
comprehensive strategy suggested below to
improve their care of difficult patients:
Acknowledge
With difficult patients, the first thing is to
acknowledge their concern. This gives both
the physician and the patient a chance to
restart their relationship. Both can pause and
reflect on questions such as—“something is
wrong, why?”
Schedule Time
A mutually convenient time and agenda are
likely to make the encounters with difficult
patients much easier. Due to limited time
available to each patient, especially in a busy
outpatient clinic, it is important for the physician
to inform that you want more time to evaluate
him/her and schedule an appointment, and be
strict about ending the encounter on time, even
if the patient has much more to say or request.
The physician can always suggest an additional
follow-up session at a later date.
Cultivate a Sense of Partnership
Physician must assure the patient that they
are equal in the same team and that they must
understand each other and work together, so
that conflicting or confusing approaches can
be avoided that may hinder treatment.
Obtain the Patient’s Perspective
Physician, by skilful questioning, should guide
the patient to narrate his/her story. Ask about
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Chapter 22: The Difficult Patient 201
Table 22.3  An approach to difficult patients
•  Exclude primary disease (or keep open mind
about it)
•  Acknowledge patient's concerns and try obtaining
patient’s perspective, i.e. their ideas, fears and
expectations
•  Take a structured history – including a socio-
psychosocial review.
•  Do a routine physical exam and screening lab
work – this will help to identify any coexisting
medical problems and assure the patient you
have been thorough.
•  Summarize main complaints and reflect back,
e.g. "Let me see if I've got this right", "Have I
missed anything?”
•  Complete any indicated testing promptly.
Limit investigations – do not fall into the trap
of ordering new tests every time the patient
describes a new symptom.
•  Work together, e.g. "let's see how best we can
together help you manage …"
•  Guide expectations toward coping rather than a cure
•  See if the patient can identify links between
symptoms and life events
•  Try a cognitive behavioral therapy (CBT) approach
•  Involve the patient, and possibly partner/family
members in finding solutions
•  Never say "there's nothing wrong, or there is
nothing I can do for you", however tempted! This
may only trigger persistent attempts to prove that
a problem exists
•  Be aware of your own negative feelings; avoid
emotional outburst
•  Set limited objectives; keep visits short and
focussed
•  Schedule regular visits – then gradually increase
the interval between visits
•  Educate yourself on cultural aspects of illness
•  Discuss with at multidisciplinary team meetings.
This may provide other ideas, support and
awareness of problem
the illness and the patient’s expectation about
what should be done. Discuss past treatment, its
outcome, any difficulties faced by the patient in
following treatment plan, and what the patient
thinks will improve the outcome.
The role of these questions is two fold.11
“First, they maximize the information physician
needs for an effective partnership with the
patient. It is a partnership that allows these
consultations to be truly effective. The more
information about the background to the illness,
 202  Section 4: The Practice of Family Medicine
the patient’s understanding and meaning, the
better it is for the physician to get involved in the
process. Secondly, they reinforce the patient’s
feelings that it is a partnership in which they
are equal. Often these consultations degenerate
into mutual hopelessness, where the patient
feels hopeless as the doctor can ‘do nothing’,
and the physician feels hopeless for the same
reason. Once both the physician and the patient
agree on achievable goals, then hopelessness
may be lifted”.
Review
This includes patient’s history, especially in
the context of bio-psychosocial factors, such
as life stressors and patient’s coping abilities.
A thorough physical examination is done
to assure the patient. Any screening or lab
tests indicated are promptly carried out and
their results are explained so that patient
understands their significance. It is usually
unwise to start with a mega work-up to rule
out any conceivable disease.2
Assess for Potential
Personality Disorder
While reviewing the patient, the physician
should be alert to note any symptoms, which
may suggest personality or psychiatric disorder
(e.g. frequent mood swings, angry outbursts,
distrust and suspicion of others, lack of interest
in social relationships, etc.). Effective treatment
of such patients requires team approach,
including mental healthcare providers.
Family Involvement
A candid discussion of the problems with
patient’s family and friends help resolve
many controversies. Their views and concerns
can be incorporated in the management of
difficult patients. Considerable tact, patience,
and understanding of the core problems are
essential for physicians to do a balancing act
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between their patients and family members.
The patient’s consent is, of course, essential
before approaching the family.
Schedule Regular Follow-up Visits
Follow-up is critical; it provides feedback and
opportunity for patients to bring up forgotten
or unaddressed issues or symptoms. They also
make patients feel cared for and understood.
Setting appointments as often as weekly at first
and gradually extended to once a month may
satisfy dependent patients.
Referral
There will be occasions when physician will
need help from colleagues. This can be obtained
from a trusted colleague, a psychotherapist, or
a support group. The one caveat is to ensure
that, “the patient does not think you are trying
to get rid of him/her. Conversely, if you are
indeed referring to another doctor or agency for
complete management, make sure the patient
understands why”.21
Coping Skills for Physicians
Handling or responding to difficult patients
requires preparation. Physicians must learn
to develop the right skills and techniques. The
authors of the Israeli study17 mentioned above
have described a variety of strategies the GPs
used to cope with the ‘difficult’ encounter
(Table 22.4).
Below are a few elements of coping skills
toward better handling difficult patients.
Empathy
Acknowledging the patient’s emotion and
offering practical, helpful action is the most
common and most effective means of coping
the patient’s distress.
Emphatic statement such as, “You are
obviously very irritated”; “I understand your
disappointment”, in a calm, serious, assertive

Table 22.4  Steinmetz and Tabenkin’s means
of coping with the difficult patient or encounter (in
descending order of relative frequency)17
1. Empathy
2. Non-judgemental listening
3. Patience and tolerance
4. Direct approach
5. Defining limits of time and content in advance
6. R eferral to various consultants, lab tests,
alternative medicine and mental health services
7. Confrontation with the patient
8. Recommendation for transfer to another doctor
9. Use of humor
10. Involving the patient’s family
11. S haring some of the doctor's personal
experiences with the patient
12. Ignoring the patient's feelings
tone, and not a sarcastic one, helps to diffuse
the emotion. The physician should become
sensitive and open to the needs of distressed
patients. A helpful action such as passing a box
of tissue paper when you notice the patient’s
eyes filled with tears, or offering a glass of
drinking water when the throat is parched,
conveys a sense of understanding the feelings
to the distressed patient.
Non-judgmental Listening
Listen openly and carefully, even when you
disagree with what’s being said. The best
way of doing this is simply to repeat back
a summary (i.e. paraphrasing) of what the
patient has said to you (called as ‘reflective or
active listening’). It is better done in a form of
statement such as: “I understand that you are
not satisfied with the service…”, or “I get the
impression that you don’t like me being late...”
Avoid imposing questions such as—“are
you telling me…,or …do you really think… ”, etc.
— because distressed patients are in no mood
to offer satisfactory replies; their thinking is
not rational. Postpone such questions and
clarifications until after the outburst.
Improve Communication Skills
In a busy practice, patient sometimes get the
impression that they are unheard or being
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Chapter 22: The Difficult Patient 203
rushed. This adds to patient’s frustration.
Misunderstandings and misinterpretations
cause more conflicts. To be certain that you
grasp the other person’s meaning, repeat what
patients have said in your own words and
ask if you have understood correctly. (“Let
me see if I understand you, but….”; “I see the
situation as ….”). Make sure you understand
how patients view their condition. Rather than
tell the patient, “there is nothing wrong with
you”, try to elicit more information: “What do
you think is the reason?.” Frequently patients
assume a certain illness they may be suffering
from based on other sources of information.
Understanding and explaining such beliefs
can spare further frustration.
Develop a Positive Attitude Toward
Patients
Affirm in your mind to serve your patients the
best you possibly can, e.g. the physician should
take the time to fully explain the patient’s
condition, treatment options, and prognosis.
Answering the patient’s questions reduces
patient apathy and apprehension.
Once you have made the commitment, the
desire to serve your patients their way rather
than your way will start to grow.
Learn to use other positive techniques,
such as positive affirmations, positive self-
talk, talk with colleagues, meditation, prayer,
exercise. They all help in positive motivation
and other emotional well-being in the patient.
Harness the Power of Self-control
Try to control yourself and avoid emotional
outbursts. Sometime after the outburst, you
will realize that you were wrong. It will be
too late. During each unpleasant experience,
think before you respond. Take responsibility
for your feelings; you can’t change other
peoples’ behavior, so you might as well charge
your own. It is best to stop blaming others
for your circumstances and take personal
 204  Section 4: The Practice of Family Medicine
responsibility for your feelings. If there are
problems to resolve “fix the problems, don’t
fix the blame” (Stephen Coscia).
Make a Conciliatory Gesture
When an issue seems to become uncom­
promising, it is wise to offer conciliatory
gestures and save all further conflicts. Some of
the gestures that may be offered are: a genuine
apology, a statement of regret, a compromise,
acceptance of responsibility for your share
of problem, a statement which indicates that
you would like to see a positive outcome to the
conflict for both parties. Say ‘Thank You’ for
giving you the opportunity to solve the problem.
Coping Skills for Family Physicians
Little has been written to date about the family
physicians’ arenas of coping with the difficult
patients. The qualitative research studies quoted
earlier16,17 describe various means of coping,
which are suitable and can be implemented in
family practice setup. These include:
1. Get the patients to meet medical students
and interns to let them get more deeply
involved with the patient and his family.
2. Presentation of a “difficult care” as learning
material for the students.22
3. Videotape presentation and discussion
with a colleague or a behavioral scientist
to analyze the interview and learn form it.
4. Learn the tools for coping with emotional
outbursts, such as anger, rejection, etc.
5. Learn relaxation techniques.
6. Undergo postgraduate training, mainly in
the field of communication.23
7. Participation in support groups with
colleagues, and groups for personal growth,
such as Balint24,25 or a joint meeting with
people who deal with behavioral sciences,
and analyzing difficult cases.
The Calmer Approach26
A practical approach that teachers and learners
can use to alleviate the stress in difficult
patients’ encounters and better management of
the patient’s needs known as CALMER model
has been developed by Pomm Ha et al,
The CALMER approach consists of six
steps; several of which only take moments to
complete:
1. Catalyst for change.
2. Alter thoughts to change feelings.
3. Listen and then make a diagnosis.
4. Make an agreement.
5. Education and follow-up.
6. Reach out and discuss feelings.
Catalyst for Change
A difficult patient with problems undergoes
‘stages of change’, which have been identified
as depicted in the Table 22.5:27

Table 22.5  Stages of change in CLAMER approach

Stages of change Explanation
•  Precontemplation Patient denies or minimizes problems. (Not yet acknowledging that there is a
problem behavior that needs to be changed)
•  Contemplation Patient acknowledges problem but not ready to change. (Acknowledging that
there is a problem but not yet ready or sure of  wanting to make a change)
•  Preparation/determination Patient commits to time and plan for resolving the problem. (Getting ready to
change)
•  Action/willpower Patient makes daily efforts to overcome problem
(Changing behavior)
•  Maintenance Patient has overcome problem for at least 6 months but must remain vigilant.
(Maintaining the behavior change)
• Relapse Patient has gone back to problem behavior.
(Returning to older behaviors and abandoning the new changes)

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In the precontemplation stage, patients are
not thinking seriously about changing and are
not interested in any kind of help. They do not
focus their attention on quitting and tend not
to discuss their bad habit with others. Patients
in this stage tend to defend their current bad
habit(s) and do not feel it is a problem. They
may be defensive in the face of physician’s
or other people’s efforts to pressure them to
quit.However, the physician endeavours to
identify the patients current status in the ‘stages
of charge’ model and serves as a catalyst for
change by giving recommendations on how the
patient can advance to the next stage of change
and eventually overcome the problem. The
physician can guide the patient before, during,
or after an interaction with a difficult patient.
Alter Thoughts to Change Feelings
The principle of cognitive-behavior therapy
that the only way individuals can control
their reactions (feelings) is to alter their
thoughts about the situation is applied. First,
the physician identifies the dominant feelings
experienced by the patient, what are the reasons
or answers for such behavior (e.g. past abuse,
poor finances, loneliness, etc.), and how these
feelings might be affecting the physician-patient
relationship and the management plans.
Depending upon their analysis, the physician
offers therapy at correcting maladaptive
feelings, thinking and behaviour that will make
the situation less distressed.
Listen and then Make a Diagnosis
By engaging in the first two steps described
above, the physician will be better equipped to
listen what patients are trying to communicate.
This will help in making more accurate
diagnosis and will lead to better working
relationship with patients.
Making an Agreement
This step attempts to reinforce physician-
patient relationship. Both the physician and
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Chapter 22: The Difficult Patient 205
the patient make a clear agreement on the
need to work on the problem together to keep
the patient as healthy as possible. Thus the
initial problem is logically followed to its end
with better outcome.
Education and Follow-up
In the process of continuing physician-
patient-relationship, physicians prescribe
“homework” to their patients depending on
their status in the ‘stages of change’ table
mentioned above. For example, a patient
who is in the stage of ‘contemplation’ to
quit smoking, the physician may prescribe
homework such as, “over the next 2 weeks,
please write down your unbiased feelings
and thoughts about the good as well as bad
effects of smoking cigarettes on your health,
irrespective of your final choice to smoke
or not to smoke. We will talk about your
experience when we meet after 2 weeks. Is that
OK?” The physician and the patient should
agree on the “home work assignment” and
the time frame in which it is to be completed.
Reach out and Discuss your Feelings
When dealing with difficult patients, physicians
do not have to feel alone. If the care of difficult
patient is becoming more stressful, it is advised
to discuss it with someone—a colleague, your
own physician, or a friend. They may point
out something you have over looked. Let them
share in the working, providing emotional
support, and the gratification that comes when
effective care leads to healthier behavior. But
be sure that your colleagues understand and
honor their absolute responsibility to respect
the privacy of these patients.2
The CALMER approach incorporates six
steps that physicians can utilize to feel more in
control and less distressed during encounters
with difficult patients. The rationale behind
“staging” people, as such, was to tailor therapy
to a person’s needs at his/her particular point
 206  Section 4: The Practice of Family Medicine
in the ‘change’ process. However, the stages
are no longer considered to be linear; rather,
they are components of a cyclical process
that varies for each individual. This strategy
is also helpful to faculty teachers to increase
the learner’s self-efficacy in managing difficult
patient encounters.
Conclusion
In the present set up of healthcare delivery
system and pressure of time to manage
patients in busy practice, the incidence
of difficult patient encounters is bound to
increase. However, being labelled as ‘difficult’
depends on the perception of the doctor
involved.
These patients have chronic, painful
problems, and interpersonal difficulties, which
are amicable more to bio-psychosocial than
biomedical approach. Learning these skills
before graduation is ideal.
Making a paradigm shift from thinking
“difficult patients” to “difficult relationships”
is the first step to manage such relationships
better.
Implementing effective strategies,
especially based on humane approach, can
enhance physicians practice satisfaction and
improve patient outcomes.
References
1. Linzer M, et al. Working conditions in primary
care: physician reactions and care quality.
Ann Intern Med, 2009;151(1):28–36, W6-9.
[PMID:19581644:Abstract]
< http://www.annals.org/content/151/1/28.
long> Accessed on 21-11-2011.
2. Strous RD, et al. The hateful patient revisited:
Relevance for 21st centur y medicine.
Eur J Intern Med, 2006;17(6):387–93.
[PMID:16962943:Free full text ]
3. Gillette RD. Problem patients: a fresh look at an
old vexation. Fam Pract Management July- Aug
2000.
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4. O’Dowd TC. Five years of heartsink patients
in general practice. BMJ, 1988;20–27;
297(6647):528–30.[PMID:3139188:Free full
text]
< http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC1840368/?tool=pubmed> Accessed on
21-11-2011.
5. Ellis CG. Making dysphoria a happy experience.
Br Med J (Clin Res Ed), 1986;293(6542): 317–8.
6. Adams J, et al. The general approach to the
difficult patient. Emerg Med Clin North Am,
1998;16:689–700.
7. Schafer Sean, et al. Personality disorders
among difficult patients disorders. Arch Fam
Med, 1998;7(2):126–9.
8. Robles R, et al. Sociodemographic and
psychopathological features of frequent
attenders in Primary Care. Actas Esp Psiquiatr,
2009;37(6):320–5.[PMID:20066583:Abstract]
< http://www.ncbi.nlm.nih.gov/
pubmed/20066583>
9. Verhaak PF, et al. Persistent presentation of
medically unexplained symptoms in general
practice.Fam Pract. 2006;23(4):414–20. Epub
2006 Apr 21. [PMID;16632487: Free full text ]
< h t t p : / / w w w . n c b i . n l m . n i h . g o v /
pubmed/16632487>.
10. Groves JE. Tacking care of hateful patients.
NEJM, 1978;298(16):883–7.
11. Christie RJ et al. Ethical issues in Fam Med.
Oxford Univ Press, 1986.
12. Steinmetz D, et al. The ‘difficult patient’ as
perceived by family physicians. Fam Pract,
2001;18(5):495–500.[PMID:11604370:Free full
text]
13. Pearce Chris. The difficult patient. Aust Fam
Phy, 2002;31(2);177–8.
14. Wade Derick T. Do biomedical models of
illness make for good healthcare systems? BMJ,
2004;329(7479):1398–401.
15. Crutcher JE, et al. The difficult patient and the
troubled physician. J fam Pract, 1980;11(6);
933–8.
16. Krebs EE, et al. The difficult doctor?
Characteristics of physicians who report
frustration with patients: an analysis of survey
data. BMC Health Serv Res, 2006;6:128.PMID:
17026762

17. Havens LL. Taking a history from the difficult
patient. The Lancet, 1978;1:138–40.
18. Hass LJ, et al. Caring for the frustrating patients.
Clinical reviews. Oct, 2001.
19. Steinmetz D, et al. The difficult patient as
perceived by family physician. Fam Pract, 2001;
18:495–500.
20. Baboolal NS, et al. Childhood sexual
abuse among outpatients attending adult
psychiatric outpatient clinics: a case-control
study. West Indian Med J, 2007;56(2):152–8.
[PMID:17910146:Abstract]
21. Nisselle Paul. Difficult doctor-patient
relationship. J of the RACGP, 2000;29(1):47–9.
22. Elder N, et al. How respected family physicians
manage difficult patient encounters. J
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Am Board Fam Med, 2006;19(6):533–41.
[PMID:17090786: Free full text]
23. Mathers NJ et al. Heartsink patients: a study
of their general practitioners. Br J Gen pract,
1995;45:293–6.[Free full text]
24. Balint M. The doctor, the patient and the illness.
2nd ed. London; Churchill Livingston, 1968.
25. Pomeroy DP. The Balint group and difficult
physician-patient relationship. J Fam Pract,
1989;29:16–17.
26. Pomm HA, et al. The CALMER approach:
Teaching learners six steps to serenity when
dealing with difficult patients. Fam Med, 2004;
36(7):467–9.
27. Prochaska JO, et al. The transtheoretical approach:
crossing traditional boundaries of therapy.
Homewood, Ill; Dow – Jones – Irwin, 1984.
 23
“The physician professional is defined not only by what he/she must know and do, but most importantly
by a profound sense of what the physician must be.”
The Association of American Medical Colleges, November 6, 2005.
Introduction
In recent times there is a growing concern
about the “quality of healthcare services”,
i.e. “achieving desired health outcomes that
are consistent with current professional
knowledge,” provided by the private and
the public sectors. 1 The symptoms of
deterioration such as steady decrease in
monitoring health care and the change of
healthcare into profit-seeking service are
visible. Newspapers scream the dreadful
headlines of surgeries gone wrong, unjustified
medical and surgical procedures, medications
with awful side effects, tainted vaccine
research, dubious drug and research claims,
and kickbacks for drug prescriptions, organ
trafficking, sharing or reusing syringes and
unsanitary conditions. As a result of such
ignoble and immoral acts millions of people
all over the world are victims of deadly
adverse drug reactions, disabling injuries and
even death. Several high profile scandals in
medicine have led to increased scrutiny of
medicine and to calls of health professionals
and managers to justify their practice in
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Medical
Professionalism
—Jordan Cohen, MD, Presidential Farewell Address
ethical terms.2 For example—in the recent
H1N1 influenza campaign, the Health
Committee of the European Parliamentary
Council has launched an investigation into
the ‘pandemic’ scandal of drug corruption
between World Health Organization, the
pharma industry and academic scientists
that has permanently damaged the lives of
millions and even caused deaths. 3 A large
number of complaints are filed against
doctors in various forums, including bringing
a malpractice claim and seeking redress in
the courts, on charges of medical negligence.
Prof. K. Ganapathy, Neurosurgeon and
Medical Director of the Apollo Telemedicine
Networking Foundation, Chennai, India,
states: “The complexity of modern medicine
leads to more opportunities for error… the
information explosion has resulted in patient
empowerment leading to decrease in medical
autonomy. Doctors must produce evidence
for their patients. The health care industry
is perceived as being too big, dangerous,
and costly to entrust its working solely to
white coated doctors. Continuous Quality
 Chapter 23: Medical Professionalism 209

Improvement (CQI)* techniques used in professionalism: engaging the mind but

monitoring industrial processes are now used
in tracking patient care. The health consumer
is trying to ensure that customer delight,
not satisfied doctors, is the new slogan for
healthcare industry.”4
Professionalism—Pitfalls
What could be the reasons for such eroded
ethics which is fundamental to our profession?
Why today’s healthcare system harms patients
too frequently and too often fails to live up to
its potential? Why we are largely characterized
as unethical? Patients seem to have lost faith
in our profession — we are seen as traders and
not health care professionals!
The answer to this thorny question is
not simple — its genesis has been attributed
to various factors. “The noble profession of
medicine, taken up as a ‘calling’ by those who
are expected to put the needs of the patient
above their own, appears to have become a
fees-for-service business model and trade.
Parental expectations, the diminishing sense
of responsibility in teachers, lack of role
models, technological advancements, sub-
specialization and third-party involvement
in the healthcare delivery system have been
identified as reasons for these concerns”. 5
There are flaws in medical education and
its implementation, such as the teaching of
professionalism in undergraduate medical
education varies widely and the strategies
used to teach professionalism are not always
adequate.6 Coulehan, in his article “Today’s
not the heart” argues, “Today’s culture of
medicine is hostile to altruism, compassion,
integrity, fidelity, self-effacement, and other
traditional qualities. Hospital culture and the
narratives that support it often embody a set
of professional qualities that are diametrically
opposed to virtues that are explicitly taught
as constituting the “good’ doctor”. 7 The
medical profession has been criticized for its
“Emphasis on remuneration, its failure to self
regulates adequately, its apparent inability
to address problems felt to be important by
society, and the fact that the profession often
puts its own welfare above that of both society
and individual patients.”8
The Evolution of Professionalism
We know for a fact that today’s healthcare
‘business’ (i.e. too greedy to truly care about
patients’ welfare) climate creates more ethical
challenges than ever before, and the society is
becoming more criticizing and urging health
care professionals to deliver their services
better. Nevertheless, there also exists a volume
of evidence that has been supportive of dignity
and honor of the healing arts;9 our colleagues
have rendered humanitarian services beyond
the hospital walls, and that our profession is no
longer viewed as being principally responsible
for the defamatory direction of the health
care —it is shared with the state, the corporate
sector, and numerous increased external
influences affecting the healthcare profession,
causing “defects in the system”.8 Thus, there

*“CQI is a disciplined approach to problem solving. The four basic building blocks of the program include:
leadership, planning, quality control, and quality improvement. It is customer focused, data driven,
and empowers the employees to meet the needs of their patients. Management teams that successfully
adopt the underlying philosophic tenets of the program and provide adequate resources for training
and implementation may realize such benefits as improved clinical outcomes, increased patient and
staff satisfaction, increased staff productivity, fewer adverse events, enhanced cost effectiveness, and
an improvement in overall organizational performance”.(Ref. web site: http://www.ncbi.nlm.nih.gov/
pubmed/11349250)

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 210  Section 4: The Practice of Family Medicine
is an opportunity for the profession per se to
address the issues facing it in an atmosphere
that is less hostile. The medical fraternity has
woken up and has decided to put its house in
order.
In a bid to re-establish its role as a
“friend, philosopher, and guide”, the medical
organizations all over the world, notably,
European Federation of Internal Medicine,
The American College of Physician, American
Society of Internal Medicine (ACP-ASIM), and
The American Board of Internal Medicine
(ABIM), gave a clarion call for a “renewed
sense of professionalism” — one that is activist
in reforming health care systems. These three
organizations designated members developed
a “charter” consisting three principles and
ten commitments, (Table 23.1) to encompass
a set of “principles to which all medical
professionals can and should aspire….which
is applicable to different cultures and political
systems, because its members share the role
of a healer, which has roots extending back to
Hippocrates.”10
Defining Professionalism
Because medicine is a “profession” and
physicians are “professionals”, it is important
Table 23.1  The charter on medical professionalism10
Fundamental principles:
• Principle of primacy of patient welfare
• Principle of patient autonomy
• Principle of social justice
Professional responsibilities:
• Commitment to professional competence
• Commitment to honesty with patients
• Commitment to patient confidentiality
• Commitment to maintaining appropriate relations
with patients
• Commitment to improving quality of care
• Commitment to improving access to care
• Commitment to a just distribution of finite
resources
• Commitment to scientific knowledge
• Commitment to maintaining trust by managing
conflicts of interest
• Commitment to professional responsibilities
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to have a clear understanding of what
“professionalism” means.
A definition of “profession” which is useful
to medical educators with responsibilities for
teaching about the professions, professional
responsibilities, and professional behavior is
suggested by Cruess SR et al11, which states,
“An occupation whose core element is work
based upon the mastery of a complex body of
knowledge and skills. It is a vocation in which
knowledge of some department of science
or learning or the practice of an art founded
upon it is used in the service of others. Its
members are governed by codes of ethics
and profess a commitment to competence,
integrity and morality, altruism, and the
promotion of the public good within their
domain. These commitments form the basis
of a social contract between a profession and
society, which in return grants the profession a
monopoly over the use of its knowledge base,
the right to considerable autonomy in practice
and the privilege of self-regulation. Professions
and their members are accountable to those
served and to society”. Society awards certain
benefits to those of a profession and may
withdraw these benefits if the obligation is
not being fulfilled. It is important to note that,
although at the heart of every profession there
is a legally sanctioned control over a specified
body of knowledge and a commitment to
service, the medical profession, in addition
to its particular knowledge and skills,
distinguishes itself from other jobs and trades
by a high code of behaviour that insists on
health care responsibility and public service.
In this context the Physician Charter
quoted above10 states “professionalism” as a
“basis of medicine’s contact with the society”.
It demands placing the health interest of
patients above those of the physicians, setting
and maintaining standards of competence
and integrity, and providing expert advice to
society on matters of health.
 Chapter 23: Medical Professionalism 211

The American Board of Internal Medicine
recently embarked on a study of medical
professionalism. In a monograph entitled
“Project Professionalism” published in 1995,
the Board characterized professionalism in
medicine as, first and foremost, requiring
the physician “to serve the interests of the
patient above his/her own self-interest.” It
specifically spelled out these six elements of
professionalism: altruism, accountability,
excellence, duty, honor and integrity and
respect for others (Table 23.2).12, 13
The Hippocratic Oath, regarded as the
cornerstone and foundation of the medical
profession, and probably the earliest code
of conduct instituted for physicians, and the
introduction of series of codes of ethics for
physicians in several different fields, such as
declaration of Geneva, declaration of Helsinki,
International code of medical ethics, etc.
describe our profession and our mission to
help those in need of care and reduce their
pain and suffering, making the welfare of the
patients the most important consideration.
Without the oath as a guide, physicians are
merely skilled workers. Practicing what is
described in the oath results in physicians’
being professionals, and most importantly, it
is not what we do as physicians but how we do
it that defines medical professionalism.14
Fundamental Ethical (Moral)
Principles15
These are moral standards laid down by society
and the medical profession to regulate the
physicians’ behavior toward their patients. The
four basic moral principles in the physician-
patient relationship are:
1. The Principle of Altruism: It is based on the
supremacy of patients’ welfare, i.e. first and
foremost, requiring the physician to serve
the health interests of patients and public
health needs above their own self-interests.
2. The Principle of Autonomy: It implies that a
patient is capable of deciding what is good

Table 23.2  Attributes in professionalism in medicine

Attributers Description Examples of deficiencies

Altruism Unconditional caring of the patient, putting Refusing to see a patient admitted at ‘odd’
others before self; the best interest of patients, hours, e.g. after midnight
not self-interest
Accountability Responsible, accountable to patients for Failure to follow up patient’s progress; failure
fulfilling the implied contract governing the to refer patient to specialists as and when
patient/physician relationship; accountable indicated
to society for addressing the health needs of
the public
Excellence Conscientious effort to exceed ordinary Casual attitude to group discussion; inability
expectations and to make a commitment to to acknowledge limited experience; not
life-long learning heeding expert advise
Duty Commitment to service; advocating the best Failing to respond to on-call messages;
possible care for the welfare of the community unreasonable delay in attending emergency
patients
Honor and Truthful with patients, families, colleagues, Accepting gifts from industry; falsifying clinical
integrity adhering to ethical and moral code; recognition evidence; plagiarizing scientific and research
and avoidance of conflict of interest articles
Respect for Treating patients, families, professional and Making derogatory comments about patients’
others other colleagues with respect; maintaining personal issues or illness; disobeying
confidentiality; maintaining respectful confidentiality
physician-patient relationship

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 212  Section 4: The Practice of Family Medicine
or otherwise, as long as those decisions
are in keeping with ethical practice and
do not lead to demands for inappropriate
care. In difficult cases, a mutually agreed
solution in the context of physician-patient
relationship helps to mitigate a particular
problem.
3. The principle of beneficence (do good)
and non-maleficence (do no harm): This
is the time honored principle of “do not
harm, prevent harm, and remove harm”,
which guides physicians while suggesting a
treatment plan. Every patient deserves and
must be provided optimal care to cure or
comfort the underlying medical condition.
4. The Principle of Social Justice: The
medical profession must promote justice
in the healthcare system, including the
fair distribution of healthcare resources.
Physicians should work actively to
eliminate discrimination in health care,
whether based on race, gender, socio-
economic status, ethnicity, religion, or any
other social category.
Ethics varies according to place, time,
circumstances, and context. For example,
traditional ethics often fall short of guiding
the complex issues involving patients in
intensive critical-care, terminal disease,
organ transplantation, assisted conception,
cloning and euthanasia and in biomedical
research. Besides, involvement of managed
care organizations and the directives of the
insurers, the ethical concerns about the
authority and trustworthiness of physicians
have become important debatable topics
in clinical ethics. Therefore, in practice,
there may be conflicts between one or more
moral principles in a given situation and
the physician has to weigh which is more
important in terms of the patient’s interests.
There may be different opinions from different
physicians depending on the values and beliefs
that the individual physician attaches to each
of these principles. It is not wrong to come to
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a different ethical action, simply because of
the different weightage given to the ethical
values. What is important is that the ethical
decision must be valid one, namely, it must be
defendable on logic.16 , 17
A Set of Professional
Responsibilities18 (See Table 23.1)
Commitment to Professional
Competence
Physicians must be committed to lifelong
learning and be responsible for maintaining
the medical knowledge and clinical and team
skills necessary for the provision of quality
care. More broadly, the profession as a whole
must strive to see that all of its members are
competent and must ensure that appropriate
mechanisms are available for physicians to
accomplish this goal.
Commitment to Honesty with Patients
Physicians must ensure that patients are
completely and honestly informed before the
patient has consented to treatment and after
treatment has occurred. This expectation does
not mean that patients should be involved in
every minute decision about medical care;
rather, they must be empowered to decide
on the course of therapy. Physicians should
also acknowledge that in health care, medical
errors that injure patients do sometimes
occur. Whenever patients are injured as a
consequence of medical care, patients should
be informed promptly because failure to
do so seriously compromises patient and
societal trust. Reporting and analyzing medical
mistakes provide the basis for appropriate
prevention and improvement strategies and for
appropriate compensation to injured parties.
Commitment to Patient Confidentiality
Earning the trust and confidence of patients
requires that appropriate confidentiality

safeguards be applied to disclosure of patient
information. This commitment extends
to discussions with persons acting on a
patient’s behalf when obtaining the patient’s
own consent is not feasible. Fulfilling the
commitment to confidentiality is more
pressing now than ever before, given the
widespread use of electronic information
systems for compiling patient data and an
increasing availability of genetic information.
Physicians recognize, however, that their
commitment to patient confidentiality must
occasionally yield to overriding considerations
in the public interest (e.g. when patients
endanger others).
Commitment to Maintaining
Appropriate Relations with Patients
Given the inherent vulnerability and
dependency of patients, certain relationships
between physicians and patients must be
avoided. In particular, physicians should never
exploit patients for any sexual advantage,
personal financial gain, or other private
purpose.
Commitment to Improving Quality of
Care
Physicians must be dedicated to continuous
improvement in the quality of health care.
This commitment entails not only maintaining
clinical competence but also working
collaboratively with other professionals to
reduce medical error, increase patient safety,
minimize overuse of health care resources,
and optimize the outcomes of care. Physicians
must actively participate in the development
of better measures of quality of care and the
application of quality measures to assess
routinely the performance of all individuals,
institutions, and systems responsible for health
care delivery. Physicians, both individually and
through their professional associations, must
take responsibility for assisting in the creation
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Chapter 23: Medical Professionalism 213
and implementation of mechanisms designed
to encourage continuous improvement in the
quality of care.
Commitment to Improving Access to
Care
Medical professionalism demands that
the objective of all health care systems be
the availability of a uniform and adequate
standard of care. Physicians must individually
and collectively strive to reduce barriers to
equitable health care. Within each system, the
physician should work to eliminate barriers
to access based on education, laws, finances,
geography, and social discrimination. A
commitment to equity entails the promotion
of public health and preventive medicine, as
well as public advocacy on the part of each
physician, without concern for the self-interest
of the physician or the profession.
Commitment to a Just Distribution of
Finite Resources
While meeting the needs of individual patients,
physicians are required to provide health care
that is based on the wise and cost-effective
management of limited clinical resources.
They should be committed to working with
other physicians, hospitals, and payers to
develop guidelines for cost-effective care.
The physician’s professional responsibility for
appropriate allocation of resources requires
scrupulous avoidance of superfluous tests
and procedures. The provision of unnecessary
services not only exposes one’s patients
to avoidable harm and expense but also
diminishes the resources available for others.
Commitment to Scientific Knowledge
Much of medicine’s contract with society
is based on the integrity and appropriate
use of scientific knowledge and technology.
Physicians have a duty to uphold scientific
 214  Section 4: The Practice of Family Medicine
standards, to promote research, and to create
new knowledge and ensure its appropriate use.
The profession is responsible for the integrity
of this knowledge, which is based on scientific
evidence and physician experience.
Commitment to Maintaining Trust by
Managing Conflicts of Interest
Medical professionals and their organizations
have many opportunities to compromise their
professional responsibilities by pursuing
private gain or personal advantage. Such
compromises are especially threatening in
the pursuit of personal or organizational
interactions with for-profit industries,
including medical equipment manufacturers,
insurance companies, and pharmaceutical
firms. Physicians have an obligation to
recognize, disclose to the general public,
and deal with conflicts of interest that arise
in the course of their professional duties and
activities. Relationships between industry and
opinion leaders should be disclosed, especially
when the latter determine the criteria for
conducting and reporting clinical trials,
writing editorials or therapeutic guidelines, or
serving as editors of scientific journals.
Commitment to Professional
Responsibilities
As members of a profession, physicians are
expected to work collaboratively to maximize
patient care, be respectful of one another, and
participate in the processes of self-regulation,
including remediation and discipline of
members who have failed to meet professional
standards. The profession should also define
and organize the educational and standard-
setting process for current and future members.
Physicians have both individual and collective
obligations to participate in these processes.
These obligations include engaging in internal
assessment and accepting external scrutiny of
all aspects of their professional performance.
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Model Behaviors of
Professionalism19,20
It may be noted that the above official
statements defining professionalism have been
mainly academic and principle based, without
a clear description of what professional
behaviors look like in practice. Therefore,
a more behavioral oriented attributes, as
determined by multiple observation-based
assessments by peers, senior residents,
facult y, me dical students, and non-
physician professionals, makes the pursuit
of professionalism, i.e. behaving in a manner
to achieve optimal outcomes in professional
tasks and interactions in daily practice more
accessible and attainable. These may be stated
as follows:
Responsibility
™™ Arrives on time and prepared for work.
™™ Appropriate dress and cleanliness.
™™ Willingly sees patients throughout the
entire shift.
™™ Writing appropriate sign-outs (e.g. patient
management plans), both giving and
receiving.
™™ Completes medical records honestly and
punctually.
™™ Appropriate use of symptomatic care.
™™ Accepts blame for failure.
Maturity
™™ Demonstrates sensitivity to patient’s pain,
emotional state, and gender/ethnicity
issues.
™™ Accepts responsibility/accountability.
™™ Effectively coordinates team.
™™ Actively seeks feedback and immediately
self-corrects.
™™ Open/responsive to input/feedback of
other team members, patients, families,
and peers.
™™ Participates in peer-review process.
 Chapter 23: Medical Professionalism 215

™™ Fairness in recruitment of residents, Reasons for Teaching

faculty, and staff. Professionalism21
Patients expect physicians to be professional: All
Communication Skills
patients want to be looked after by doctors with
™™ Is not hostile, derogatory or sarcastic. up-to-date medical knowledge and clinical
™™ Is not loud or disruptive. skills, strong ethical standards and bedside
™™ Maintains patient confidentiality. manners that is empathetic, courteous and kind.
™™ Protects staff/family/patient’s interests/
confidentiality. Teaching and assessing professionalism does
™™ Discusses death honestly, sensitively, not occur by chance alone: The elements of
patiently, and compassionately. professionalism discussed earlier should be
™™ Uses humor/language appropriately. intentionally taught, which requires formal
curricula and authentic fostering of a culture
™™ Is patient.
of profes­sionalism in learning environments.
Respect Professionalism is associated with improved
™™ Unconditional positive regard for the medical outcomes: Professionalism results
patient, family, staff, and consultants. in increased patient satisfaction and trust;
™™ Treats patients/family/staff/para­ increased patient adherence with treatments,
professional personnel with respect. increased likelihood patients will stay with a
™™ Is sensitive to physical/emotional needs. physician, fewer patient complaints, and less
™™ Is not biased/discriminatory. patient liti­gation. In addition, professionalism
is associated with overall physician excellence
including medical knowl­e dge, skills and
Unprofessional Behaviors18
conscientious behaviors.
™™ Substance abuse and/or dependence.
™™ Abandons patients. Unprofessional behavior is associated with
™™ Refractory lying, cheating, stealing. adverse medical outcomes: for example,
™™ Unable or unwilling to learn from past reduced employee morale and pro­ductivity,
mistakes. re duce d nurs e satis ­faction, re duce d
™™ Fails to show up for work. communication, teamwork and efficien­c y,
higher costs and decreased learner satisfaction,
™™ Discriminates against others based on
burn­out, and depression.
race, creed, gender, or sexual orientation.
Medical professional societies expect
™™ Takes risks that seriously threaten safety of
or require it. There is a growing consensus
patients and staff.
among medical educators and accreditation
™™ Harasses or unfairly punishes students/
organizers that to promote the professional
patients/staff.
development of medical students, schools
™™ Verbally or physically assaults patients/
of medicine should provide explicit learning
family/staff.
experiences in professionalism.
™™ Falsifies medical records or research data.
™™ Inappropriate sexual contact with patients,
students, or staff. The Educational Challenge
™™ Personal life interferes with work. Perhaps the most ideological issue of medical
™™ Unkempt appearance or poor grooming. professionalism is the question of how to
™™ Suggestive or sloppy dress. implement and enforce professional standards.

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 216  Section 4: The Practice of Family Medicine
A review of the literature suggests that
professionalism is not completely understood
or practiced.22 Although many approaches have
been suggested to achieve this goal, such as
periodic board recertification, Balint training,
involving consumer groups and media as
watchdog committees, imposing legislations
on health matters, policies to minimize the
influence pharmaceutical companies and
their representatives, 23,24 the one striking
observation is, “the lack of literature dealing
with professionalism available to the average
doctor. When this is coupled with the absence
of relevant material in the curriculum of most
medical schools, it is understandable why,
in a rapidly changing world, doctors may not
have a clear understanding of what the public
expects from its professionals ... most doctors
do not fully understand the obligations they
must fulfill to satisfy public expectations and
maintain professional status. However, the
doctors will meet their obligations if they
understand their origins and their nature.
Therefore, professionalism must be taught”.8
Medical schools, teaching hospitals, and
those responsible for continuing medical
education should teach professionalism as a
subject formerly identified in the curriculum.
The teaching of professionalism should
include several components:8
™™ Identifying educational content in the
undergraduate medical school curriculum
devoted to professionalism which should
be reinforced in postgraduate programmes
and in continuing medical education. The
subject should be part of the evaluation of
all students.
™™ A clear definition of professionalism and
its characteristics.
™™ Knowledge of codes of ethics governing the
doctor-patient relationship.
™™ Professionalism as an ideal to be pursued,
emphasizing its inherent moral value. The
concept of altruism must be highlighted as
essential to professionalism.
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™™ Relevant material drawn from sociology,
p h i l o s o p h y , e c o n o m i c s, p o l i t i c a l
science, and medical ethics as related to
professionalism, including interpretations
of both the historical course of events and
of doctors’ behavior that are critical of the
medical profession.
™™ The link between professional status and
the obligations to society must be fulfilled
to maintain public trust. These obligations
should be explicitly outlined and included
in the teaching.
The teaching of professionalism begins with
the first year medical student in the classroom
and continues as the student progresses into
the clinical arena. A curriculum that includes
clinical and professional ethics, social issues
in medicine, community service activities, and
longitudinal patient care is necessary. It is the
responsibility of the institution to create an
environment for professionalism, have leaders
who are involved with mentorship, and ensure
that the entire faculty is contributing to the same
outcome.25
Conclusion
With the changing values and in a competitive
world, the practice of medicine is beset
with unprecedented challenges. The waves
of consumerism, enterpreneurism, and
commercialism are threatening to drown what
is professionalism. To maintain the fidelity of
medicine’s social contact during this turbulent
time, the physician must reaffirm their active
dedication to the welfare of patients and society.10
Professionalism, long a consideration
of physicians and patients, is coming to the
forefront as an essential element of medical
curriculum. Ethics should be thought to
medical students actively and must not be
relegated to a ritual of the Hippocratic Oath.
The next generation of practicing
physicians must regain the high degree of
public trust that medicine once experienced
 Chapter 23: Medical Professionalism 217
by understanding their obligations to society
and by maintaining their position not just as
students of science but also as disciples of
learning and wisdom.24
References
1. Shipon DM, et al, Quality in health care: what
are the problems and what are the solutions?
Tex Med. 2000;96(10):61–5. Review. [PMID:
11070737:Abstract]
2. Parker JM. Getting ethics into practice. BMJ,
2004;329:126.
3. F. William Engdahl. European Parliament to
Investigate WHO and “Pandemic” Scandal.
Web site : http://www.european-hospital.
com/en/article/6837-European_Parliament_
to_Investigate_WHO_and_%22Pandemic%22_
Scandal.html
4. Ganapathy K. Patient power. The Hindu; 14th
Dec. 2003.
5. Sivalingam N. Teaching and learning of
professionalism in medical schools.Ann
Acad Med Singapore. 2004;33(6):706–10.
[PMID:15608822:Free article]
6. Swick HM, et al. Teaching professionalism
in undergraduate medical education JAMA.
1999;282(9):830–2 [PMID:10478688: Abstract]
7. Coulehan J. Viewpoint: today’s profession­alism:
engaging the mind but not the heart. Acad Med.
2005;80(10):892–8.[PMID:16186604:Abstract]
8. Cruess SR, et al. Professionalism must be
taught. BMJ, 1997;20–27;315(7123):1674–7.
[PMID: 9448538: Free article]
9. Freidson E. Professionalism reborn. Chicago.
University of Chicago Press, 1994.
10. Me d i ca l Pro f e ssi o na l i sm i n t he Ne w
millennium: A Physian Charter. Project of the
ABIM foundation, ACP-ASIM Foundation, and
European federation of Internal Medicine.
Annals of Int Med, 2002;136(3):243–6.
11. Cruess SR, et al.”Profession”: a working definition
for medical educators. Teach Learn Med, 2004
winter; 16(1):74-6. [PMID: 14987179: Abstract]
mebooksfree.com
12. American Board of Internal Medicine: Project
Professionalism, 1995.
13. Schwartz, Ann C, et al. Developing a Modern
Standard to Define and Assess Professionalism
in Trainees; Acad Psychiatry, 2009;33:442–50.
14. Har r is GD. Professionalism : Par t I –
Introduction and being a role model. Fam
Med, 2004;36(5): 314–5.
15. Longmore M,et al. Oxford Handbook of Clinical
Medicine 5th edn. Oxford University Press.
2001:17.
16. Goh L G. The doctor-patient relationship.
Singapore Fam Phy: 1993;19(1).
17. Iyalomhe GB. Medical ethics and ethical
dilemmas. Niger J Med, 2009;18(1):8–16.
Review. [PMID: 19485140: Abstract]
18. Me dica l P rofessiona l ism in th e New
millennium: web site -http://www.annals.
org/content/136/3/243.full
19. Larkin GL et al. Defining and evaluating
professionalism: A core competency for
Graduate Emergency Education. Academic
Emerg Med, 9(11):1249–56.
20. Reed DA, et al. physicians. AMA. 2008;
300(11):1326–33. [PMID: 18799445: Free
article]
21. Mueller P S. Incorporating Professionalism
into Medical Education: The Mayo Clinic
Experience .Keio J Med, 2009;58(3):133–143.
22. Gaiser RR. The teaching of professionalism
during residency: why it is failing and a
suggestion to improve its success.Anesth
Analg, 2009;108(3):948–54. Review. [PMID:
19224808: Free article]
23. Adams KE, et al. Effect of Balint training on
resident professionalism. Am J Obstet Gynecol,
2006;195(5):1431–7. Epub 2006 Sep 25. [PMID:
16996457]
24. Rothman DJ. Medical Professionalism –
Focusing on real issues. New Eng J med, 2000;
342(17):1284–6.
25. Harris GD. Professionalism: Part II– Teaching
and Addressing the Learner’s Professionalism.
Fam Med, 2004;36(6): 390–2.
 5
Section

Adolescent Health
™™ Adolescent Care
™™ A Problem Adolescent

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 24 ADOLESCENT CARE

“There is no greater challenge in the world than that of being a parent.”

Introduction Although for the majority of young people

On the eve of the World Population Day,
11 July, 2011, Dr Babatunde Osotimehin,
United Nations Population Fund (UNFPA)*
Executive Director, while addressing the world
of 7 billion, put forth his vision: “This year,
on October 31st, world population reaches 7
billion. This milestone represents a challenge,
an opportunity and a call to action, we have
an opportunity and responsibility to invest in
the world’s 1.8 billion adolescents and youth
aged 10–24 years. They constitute more than a
quarter of the world’s population and almost
90% live in developing countries. Every young
person deserves education, including sexuality
education and access to comprehensive health
services. With the right policies, investments
and social support, young people can enjoy
healthier lives free of poverty and enhance
prospects for peace and stability”.1
The above message of hope and action
clearly distinguishes adolescents as an
emerging significant proportion of the
population group which transcends the
confines of geography, economics, education,
culture and race.
adolescence is not a tumultuous developmental
period, there is a significant group of young
people for whom the adolescence is associated
with considerable morbidity and concerns
about medical issues.
Adolescence is a time of many transitions
both for teens and their families. To ensure
that teens and adults navigate these transitions
successfully, it is important for both to
understand what is happening to the teen
physically, cognitively, and socially; how these
transitions affect teens; what adults can do;
and what support resources are available.
However, at present times certain health
problems have emerged which are closely
related to the lifestyle of teenagers. Young
people are being targeted increasingly by the
music, fashion, and leisure industries, and
this “youth industry” shapes to a considerable
extent, the evolving patterns of youth culture.2
Obesity, substance use and abuse (e.g. tobacco,
alcohol, illicit drugs, and inhalents), unprotected
sex, disruptive behavior, mental illness and
nutritional deficiencies are common health
problems in the adolescents. The major causes

*UNFPA, the United Nations Population Fund, is an international development agency that promotes
the right of every woman, man and child to enjoy a life of health and equal opportunity. UNFPA supports
countries in using population data for policies and programmes to reduce poverty and to ensure that
every pregnancy is wanted, every birth is safe, every young person is free of HIV/AIDS, and every girl and
woman is treated with dignity and respect.

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 222  Section 5: Adolescent Health
of injury and death in the adolescents are
motor vehicle and other road traffic accidents,
homicide, and suicide. It’s a common knowledge
that preventive services particularly needed are
for addictive problems, emotional disorders,
suicidal states, and conditions related to sexual
activity.3-6 These health needs are not met by
existing health care delivery systems. At present,
there is no unified approach to the development
of health care programs for adolescents, but
important explorations of effective methods are
taking place in a fragmentary way. The challenge
is to provide the necessary technology and
professional expertise in an accessible setting
and then to weld these services into programs
which will become cohesive and stable.7
With rapid industrialization, urbanization
and erosion of traditional social cultures,
adolescent healthcare in the primary sector
are fast gaining its importance in the present
modern society, especially in developing
nations. A major goal in the healthcare of today's
youth is to increase access to and use of health
services for adolescents, and to strengthen
contributions from the education, media and
other communication sectors to improve
adolescent health so that adolescents can
become knowledgeable about the relationship
between their lifestyle and their physical and
mental health.8 They also need help in achieving
the maturity essential to choosing a healthy
lifestyle and accepting responsibility for their
personal health. In this context, family physicians
and primary care clinicians, who are trained to
integrate physical, psychological, social, cultural
and existential factors, utilizing the knowledge
and trust engendered by repeated contacts,
can play a critical role in preventing adverse
outcomes and promoting healthy lifestyles.9,10
Furthermore, in family practice, adolescents
*The term, “emancipation” refers to the point at which a minor becomes self-supporting, assumes adult
responsibility for his/her welfare, and is no longer under the care of his or her parents. Upon achieving
emancipation, the minor thereby assumes the rights, privileges, and duties of adulthood before actually
reaching the "age of majority" (adulthood).
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account for significant patient population,
requiring primary healthcare needs. Surveys
show that teenagers have many health concerns,
though they do not always tell their GP about
them; however, they do visit their GPs on an
average 2–3 times a year (with about 70% of
all teenagers visiting their GP in any one year).
These visits provide opportunities to deal with
their health concerns.11 Therefore, it behooves
family physicians to respect these findings and
foster an improved atmosphere, and provide
improved health care and establish enhanced
level of confidence and motivation in them.
Definition
Adolescence is the transitional period of
development involving two important
physiological and psychological aspects —
from childhood to adolescence, encompassing
puberty, and that from an increasingly protracted
adolescence to adulthood2— involving multiple
physical, intellectual, personality, and social
developmental changes.
Technically, adolescence is a period from
the beginning of sexual maturity to completion
of physical growth.
Adolescence begins with the onset of
physiologically normal puberty, and ends
when an adult identity and behavior are
accepted. This period of development
corresponds roughly to the period between
the ages of 10 and 19 years.
Although adolescent phase ranges from
age 10–19 years (age 11–21 years is also
included by some authorities), it is to be
noted that those responsible for providing
healthcare to adolescents must allow sufficient
flexibility in this age span to encompass special
situations such as an emancipated minor*
or a young person with a chronic condition

leading to delayed development or prolonged
dependency.12
World Health Organization defines
adolescence* as a progression from appearance
from secondary sexual characteristics to sexual
and reproductive maturity, development
of adult identity, and transition from total
socioeconomic dependence to independence.
However, while adolescence is a recognizable
phase of life, its end is not always easily
demarcated. This poses problems for
practitioners when adolescent patients require
care in facilities with restrictive age limits.12
Adolescent Consultation
It is important to recognize that adolescents
often have little knowledge of primary care,
except for their experience as children when
they were accompanied by parents or relatives.
It is a commonly seen that appointments for
adolescents tend to be made by parents, and
this “parental involvement” in scheduling
appointments for their sons and daughters
(irrespective of age) is found to be an
important factor in yielding better compliance
to consultation appointments.13
There is no standard approach to
consulting with adolescents that is found
to be most successful. Neither the standard
“pediatric” consultation (i.e. doctor normally
communicates with parents), nor the standard
“adult” consultation (i.e. doctor mostly
communicates with the patient), is appropriate
for adolescents.13
Initially, it is best to see adolescents
together with their parents, and after the
parents’ narration is over, adolescents should
be interviewed individually. A useful beginning
is an initial introductory meeting with both
the adolescent and parents. During this
*WHO defines “adolescents” as individuals in the 10–19 years age group and “youth” as the 15–24 years
age group. These two overlapping age groups are combined in the group “young people” covering the age
range 10–24 years.( web site - http://www.searo.who.int/en/Section13/Section1245_4980.htm)
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Chapter 24: Adolescent Care 223
initial encounter, establish what the parents'
concerns are, obtain a family history, and
ask about previous medical problems. This
begins the transition from parent to teen as
the medical historian. Next, ask parents to
wait in the waiting room so that the physician
can speak privately with the adolescent. The
physician interviews the adolescent alone,
perform a physical examination with a
chaperone, and then invite the parents back
into the room at the conclusion of the visit to
discuss clinical findings. Such an approach
gives the message that the physician is treating
them with respect as individuals and that their
opinion is important.
There are occasions when physicians face
problems to come to an amicable solution,
especially when dealing with their life-
style behavior. At such times, the physician
should try to concentrate on areas where
the adolescent is doing well, keeping the
discussion positive.
Although adolescents are assuming greater
responsibility for their own health care, yet
they have a high rate of broken appointments.14
When adolescents visit physician’s office,
they frequently comment on number of
potential negative issues such as uncaring
staff, delays in appointments, uncaring health
professionals, breaches in confidentiality,
unfriendly atmosphere, inappropriate health
promotion, and lack of respect for their
viewpoints. It is therefore essential for the
physician to respect these feelings and foster
an improved atmosphere in which they
feel more comfortable and respected, and
thus improve their understanding of the
potential negative outcomes associated with
noncompliance to improve appointment-
keeping behavior.15
 224  Section 5: Adolescent Health
Exploring Hidden Agenda it is based on mutual respect. This requires
speaking to the adolescent alone after obtaining
Adolescents normally present to primary care
another relevant history from parents.
physicians with routine health problems,
Providing confidential services is an
such as upper respiratory tract infections,
essential part of adolescent health care
minor injuries, allergies, acne; and long-term
that works best with the alliance of parents.
health needs such as immunization, asthma,
Further, educating parents about privacy
diabetes, migraine etc.
issues results in a significant improvement
On the other hand, it is important to
in parental opinion about confidentiality;
appreciate that adolescents have health
an over whelming majority of parents
issues that they may not desire to openly
support the idea that teens should speak
share with physicians (hidden agenda); they
with a provider alone if the teen so desires,
often conceal some of the health issues they
suggesting that parents acknowledge a need
choose to discuss (e.g. being pregnant or
for independence.17
having sexually transmitted infection), or
Although adolescents, as they grow
parents may disregard certain health issues
older, become increasingly concerned that
(e.g. teenage depression) presuming they are
their health information should remain
not the major issues for their teens. However,
confidential, it is vital for the physician to
they need to be addressed to enhance good
clarify the limits of confidentiality as early
health. Therefore, the physician skillfully
as possible during the consultation if the
has to develop a supportive environment by
physician feels the patient is at serious risk
astutely observing the adolescent’s both verbal
of significant harm such as suicide, physical
and non-verbal emotions and expressions,
or sexual abuse, or reveal plans to harm
and by actively listening to their problems
others. However, it is important to include the
and giving them an opportunity to voice their
adolescent along with parents in the process
concerns, the physician can explore issues that
of revealing confidential information despite
concern the adolescent.
the trouble and inconvenience it might cause.*
Confidentiality
Adolescents seek health care on their own History
initiative or at the suggestion of their parents. The presence of the parent or guardian while
They may come alone or at least with one eliciting the formal history of the patient
parent or a relative. In either case, they are enhances its accuracy and completeness. An
often worried about breaches of confidentiality, initial focus on "getting to know" the patient
especially about sensitive issues such as with questions about routine home and school
contraception, pregnancy, HIV, and drug activities, interests, or hobbies is useful in
abuse.16 It is therefore essential for the treating reducing the patient's anxiety. Subsequently,
physician to make it known to both the parents after establishing an effective relationship with
and the young the importance of confidentiality the patient, the formal information about the
in your practice; emphasizing to both the reason for visit, i.e. chief complaint, and the
parent and the adolescent that the confidential history surrounding it, i.e. history of present
relationship is not based on “keeping secrets”; illness can be elicited.

*Adolescent consent and confidentiality laws vary from state to state. Physicians and other healthcare
providers must be aware of the health implications of federal policies, common law, and their individual
state's laws pertaining to this topic.

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 Chapter 24: Adolescent Care 225

The history seeks information to assess how
well the adolescent is currently functioning in the
physical, emotional, and cognitive spheres (Table
24.1). Much attention is focused on the patient’s
progress through puberty and adolescence,
i.e. the onset, sequence, characteristics, and
interrelationships of the critical features of
pubertal growth and development (sexual
maturation, increases in height and weight,
completion of skeletal growth accompanied by
a marked increase in skeletal mass, and changes
in body composition).*
Besides the comprehensive medical history
which includes any acute or chronic medical
issues, the current list of medications, medication
allergies, and vaccination, psychosocial history
and family interrelationships are explored in
greater detail.
It is prudent to request the parent or guardian
to wait in the reception room before asking
the patient more sensitive and confidential
history, especially related to adolescent’s family
relationships (parents and siblings), relationship
with peers, teachers, and friends, parental abuse
(physical, emotional or sexual), drug abuse,
alcohol, tobacco and sexual habits.
Providing the adolescent a standard
questionnaire** to complete at home before
the first office visit can be a time-efficient and
useful way to manage limited time available to
the physician to discuss more pressing issues
during the initial visit.
One method of getting a through adolescent
history is the “HEADDSS” approach (Table
24.2), a formula designed for both genders,
which reminds physicians to cover the
important domains of psychological and
behavioral development. Parents, family
members, or other adults should not be
present during the HEADDSS assessment
unless the adolescent specifically gives
permission or asks for it.
If intensive, long-term treatment is required,
physicians may need to refer the young
person to an appropriate treatment service.
Referral to specific health professionals, such
as psychologists, drug counsellors or social
workers, may also be necessary, depending on
the outcome of the assessment.
Before ending the interview, give the
adolescents an opportunity to express any
concerns the physician has not covered, and
ask for feedback about the interview. Try
to provide whatever educational materials
or information brochures young people are
interested in.

Table 24.1  Psychosocial processes and substages of development

Adolescent substages Emotional Cognitive Social
Early Adjustment to new body Concrete thinking ↑ peer bondage
(11–14) image
“Am I Normal?”
Middle Emotional separation from ↑Abstract thinking ↑ health risk behavior,
(15–17) parents ↑ verbal ability ↑ sexual interest in peer,
“Who Am I?” ↑ school demands ↑ early vocational plans
Late Personal sense of identity Further development of ↑ impulse control,
(18–20) abstract thinking, its rele­ ↑ social autonomy,
“Where am I going?” vance to personal life values ↑ vocational capability,
↑ intimate relationships

*For normal physiological information about pubertal growth and development, the web site < http://
www.usc.edu/student-affairs/Health_Center/adolhealth/content/a1.html> may be helpful.
**A basic adolescent health screening questionnaire is available at the web site - < http://www.ahckolkata.
org/questionnaire.html>.

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 226  Section 5: Adolescent Health
Table 24.2  Example of HEADDSS screening
questions
H Home/health
•  Where and with whom do you live?
•  Are your parents your legal guardians?
•  How well do you get along with the people you
live with?
•  How is your health in general?
•  Do you have any health problems?
E Education/employment
•  Do you go to school?
•  What grade are you in and what school do you
attend?
•  Are you in a specialized education program?
•  Do you have a job?
A Activities
•  What do you do for fun?
•  Do you have friends to socialize with?
D Drugs
•  Do you smoke?
•  Do you drink? If so, how much and how often?
•  Do you use drugs?
D Depression (including suicidal feelings)
•  Do you ever feel depressed?
•  What do you do to cheer yourself up?
•  Do you ever want to hurt yourself?
•  Do you have anyone to discuss your problems with?
S Safety
•  Do you feel safe at school?
•  Do you feel safe at home?
S Sexuality
•  Have you ever had sex?
•  Are you using birth control?
•  Do you use condoms every time you have sex?
•  Have you ever been pregnant?
•  Did anyone ever make you do something that you
didn’t want to do?
Source: Adapted from the Minnesota Health Improvement
Partnership Services Action Team in partnership with the
Minnesota Department of Health, Updated 2006. Originally adapted
from Goldenring JM, Cohen E. Getting into adolescent heads.
Contemp Pediatr 1988; 5(7): 75-90. (website- http://medschool.
ucsf.edu/sfghres/fhc/HCM/HEADSS.htm Accessed on 20-12-11).
Adolescent Communication
It can be extremely difficult communicating
with young people. Early adolescents generally
find difficulty in expressing themselves, and
rarely volunteer information. They are often
self-conscious and avoid eye contact. In
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general, adolescents expect the physician to
use understandable adult language and not
the teen jargon.
The physician, either before or at the time
of the initial visit, should establish the “limits of
confidentiality” with the patient as well as his
or her parent(s) or guardian. After the parents
have had their say, a separate consultation
with the young person alone will help create
an impression of respect and confidence.
One example of effective statement is, "Our
conversations will be between you and me
alone unless I consider something to be of
danger to you or others. In such instances,
although I will not discuss it behind your
back, I will share such information with your
parent(s) and I will ask you to be present.
Regarding your diagnosis and any treatment
required, you and I will discuss what you wish
to be shared with your parent(s) and whether
you, I, or both of us will talk with them about
it." A clear statement in this regard provides
the basis for a mutually trusting relationship
between the physician and the adolescent as
well as the physician and the parent(s).18
The key skills required for effective
communication with adolescent are:
™™ Provision of a physically and emotionally
safe environment in which clinical
interaction can take place.
™™ Strict confidence.
™™ Listening skills.
™™ Empathy.
™™ Patience and endurance.
™™ Encouragement.
™™ Respect, non-critical, non-judgmental.
™™ Understanding the link between physical
and emotional well-being.
Communication Techniques
Certain simple techniques for making
communication effective are:
1. KISS—keep it simple and sweet—In
communicating with adolescents, care

should be taken to keep the conversation
short and sound as sweet as possible. They
should never have the feeling that elders
are disinterested.
2. VAK – Principle:
V—Visual—Eye contact is most important
in communication.
A—Auditory—Implies attentive listening.
K—Kinesthetic—The kinesthetic feel/touch
or any gesture of appreciation, e.g. pat on
the shoulder will definitely strengthen their
confidence.
3. Sandwich technique:
In this technique, the most difficult
situation is cleverly sandwiched in between
and the good qualities projected. It is an
indirect way of saying unpleasant things
in the sweetest manner and temporarily
hiding its significance without causing any
displeasure. This approach encourages to
develop a positive approach to life and to
see things in a lighter perspective. For this,
the guidance of a mature dependable adult
is essential.
Certain expressions to be avoided in
communicating with adolescents are -
(mnemonic “A D O L E S C E N T”):
A – Accusing
D – Demanding
O – Over expectation
L – Lying, laziness
E – Evaluating, judging
S – Soreness
C – Comparing
E – Error highlighting
N – Negative emphasis
T – Transferring our problems
Physical Examination
Adolescents are acutely aware of his/her body
and the changes that may or may not have
occurred. The intimate nature of physical
examination has the potential to magnify
anxieties in body image. Therefore, it is
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Chapter 24: Adolescent Care 227
important for the physician to diffuse anxiety
that may be either generated or accentuated by
the examination. This may be accomplished
by:
™™ Providing an examination gown that covers
the trunk and pelvic area, prior to the
patient’s disrobing,
™™ Ensuring privacy and respecting modesty,
™™ Providing thorough explanations as the
examination proceeds (e.g. what are
you doing and why you are doing it; the
conversation should be appropriate to the
area being examined),and
™™ Offering reassurance about findings that
are normal.
Special attention is focused on:
™™ Vital signs: height, weight, blood pressure
– sitting and supine,
™™ Skin: acne, hyperkeratosis, hyperhidrosis,
and in females hirsutism,
™™ Breasts and genitalia: staging of the
genitals in the male, breasts in the female,
and pubic hair in both; breasts in the male
for possible gynecomastia,
™™ Teeth: for obvious dental pathology,
™™ Vision: visual activity,
™™ Ears: hearing, and
™™ Orthopedic concerns: back for scoliosis
(particularly females) and dorsal kyphosis.
A rectal examination in males is required
only when there is a suspicion of prostate
or bowel disease, unexplained anemia, or
homosexual activity. In the latter instance, a
rectal culture for gonorrhea should be obtained.
A female pelvic examination is required
when there is a suspicion of disease, abnormal
secondary sexual development, pregnancy,
contraception is requested, or the patient is
sexually active. If an examination is performed,
a baseline pap smear and culture for gonorrhea
should be obtained.18
The Table 24.3 summarizes the major
elements for clinical interaction with young
people.
 228  Section 5: Adolescent Health
Table 24.3  Improvements practices can make
Reception staff
•  T rain receptionists to show consideration to
adolescents.
•  It may not be necessary to ask why an individual
wishes to see the physician.
•  Try to encourage a friendly atmosphere in the
waiting room.
•  Maintain respect and confidentiality of the individual.
Health professionals
•  In consultation, show respect for the individual.
•  See young people by themselves as well as with
their parents.
•  Maintain non-authoritarian, non-judgmental attitude.
•  Allow time to put young patients at their ease.
•  C onduct examination in a friendly, courteous
manner.
•  Be yourself, maintain appropriate boundaries.
•  A ssure confidentiality – both in the clinical
interaction and hospital set-up.
•  Look for any ‘hidden agenda’ and consider the
possibility of a psychological element.
•  P rovide health advice in the context of the
consultation.
Counseling
Adolescence is a unique rapid developmental
period, both biologically and psychologically,
between puberty and maturity. This upsurge
of changes in biological, psychological and
social aspects sometimes lead to behavioral
contradictions. They often feel stuck between
wanting independence and still needing
guidance. The roles and responsibilities
that are expected by the society and the
conflict between the actual expectations and
achievements of the adolescents put them in a
state of confusion, a sense of guilt and anxiety
in some situations. This state is sometimes
referred as “cognitive dissonance”*—a state
of confusion and clouding that occurs in the
thought process of a person. The cognitive
dissonance in adolescent patient, entangled
in a time of major physical, emotional, social,
and cognitive growth and development, poses
a unique challenge to the physician.
In general, the features that lead to
cognitive dissonance in adolescents are:
™™ Growth concerns: The prominence of
physical changes is a matter of concern
to adolescents. Ignorance of biological
changes that occur rapidly in the body often
lead to a state of fear and embarrassment,
especially among adolescent girls. This
can to a great extent alleviated by proper
parental guidance.
™™ Sex and sexuality problems: With the
development of secondary sexual features,
adolescents are curious and inquisitive about
sex related issues. Parents and teachers also
do not have clarity of thinking and comfort
level to discuss sexual matters. In their hunt
for more information on sex, they fall easy
prey to promiscuous behavior. Teenage
love affairs, teenage sexuality/pregnancy,
homosexuality and such perverted sexual
relationship further aggravate development
of normal interpersonal relationship.
™™ Emotional problems: Adolescents by their
very nature are sensitive individuals,
making them prone to emotional outbursts.
The stress and strain of modern society
have led many adolescents to extreme
steps of committing suicide. This tendency
of escapism is an unhealthy sign that needs
to be discouraged. Emotional control can
be attained only through proper nurturing.

*The term cognitive dissonance describes a psychological state in which an individual’s cognitions—beliefs,
attitudes, and behaviors—are at odds (Festinger, 1957). Cognitive dissonance is the mental conflict that
occurs when beliefs or assumptions are contradicted by new information. The unease or tension that the
conflict arouses in a person is relieved by one of several defensive maneuvers: the person rejects, explains
away, or avoids the new information, persuades himself that no conflict really exists, reconciles the
differences, or resorts to any other defensive means of preserving stability or order in his conception of the
world and of himself. (Ref. http://www.britannica.com/EBchecked/topic/124498/cognitive-dissonance).

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™™ Academic problems : High academic
achievements from adolescents, increasing
competition in securing admission to
professional schools and job opportunities,
financial instability, scholastic
backwardness are yet other perpetuating
factors in most of the academic problems
faces by the adolescents. Poor performance
in subjects and examinations create a
sense of inferiority complex, leading to
aversion to the subjects, which in turn
leads to school abstinence and falling into
bad company. The increasing number of
suicides is an indication of growing distress
in the adolescent population with regard to
academic expectations.
™™ Involvement in social issues: It is not
uncommon to see today’s adolescents and
youths involved in anti-social activities,
destructive agitations leading to strikes,
campus fights, and even murders and
similar criminal activities.
Adolescents visit physicians infrequently.
When they do, few receive counseling on critical
adolescent health issues.23 Often physicians
feel overwhelmed by or uncomfortable with
counseling teenage patients about sensitive
areas such as sexuality or drug and alcohol use.
However, both family physicians and
pediatricians have room for improvement.
Providing appropriate health care to
adolescents in an effective manner, terms
of preventing the onset of health-risking
behaviors and promoting a healthy lifestyle,
requires an in-depth understanding of
these changes. As many chronic diseases of
adults have their origins during adolescence,
this approach holds promise for reducing
morbidity and mortality in later life as well as
during young adulthood.
Evidence shows that quality of health care
improved in adolescents who received more
comprehensive screening and counseling,
more health education materials and had
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Chapter 24: Adolescent Care 229
greater access to care after implementation.24
Further, studies also support the efficacy of
providing training, tools, and resources as a
method increasing preventive screening and
counseling of adolescents across multiple risky
health behaviors during a routine office visit.25
Brief counseling interventions by physicians
or other clinicians have been shown to be
effective in modifying health risk behaviors in
adolescents. Adolescents also have indicated
both a belief that physicians should counsel
them on risk behaviors and a willingness to
discuss risk behaviors if asked about them in
a confidential manner.26
The key to providing relevant and useful
preventive Counseling for adolescent patients
is developing the trust necessary to discuss
the specific issues that impact this age group.
Therefore, primary care physicians, with their
long-standing association with families, have an
important role to play in promoting adolescent
health through a strategy of providing health
guidance to adolescents and parents, screening,
and promoting immunizations.
Physicians and other primary care health
providers may use recommendations, such as
Guidelines for Adolescent Preventive Services
(GAPS)27-29 developed and promoted by the
American Medical Association's Department
of Adolescent Health and American Academy
of Pediatrics' Health Supervision Guidelines, to
expand the quantity and quality of preventive
services they offer to adolescents. These
elements include:
™™ Providing a framework for the organization
and content of well-adolescent care (see
“adolescent care clinic” below),
™™ Offering guidance for parents and families
as an essential part of adolescent health
care, and
™™ Dealing with a wide range of adolescent
health problems, with an appropriate
focus on the behavioral, emotional, and
developmental aspects.
 230  Section 5: Adolescent Health
Although, guidelines for clinical adolescent
preventive services recommend that primary
care clinicians routinely screen for and counsel
adolescents about behaviors, identify and
address related social, psychological and
biologic factors, there is lack of well-defined
theory-based models for adolescent office-
based counseling, the complexity of measuring
counseling quality, and the many factors that
influence adolescent outcomes.30,31 However,
since physicians’ are dealing directly with
adolescents, their work involves matters of
sensitive and confidential nature. Therefore,
they need to exhibit certain skills and qualities
to perform well in this profession:
™™ Listening more than talking
™™ Empathy
™™ Professionalism
™™ Effective communication
™™ Constructive in approach
™™ Confidentiality
™™ Respect for religious beliefs and customs
™™ Individual freedom.
In some adolescent care centers, new
cost-effective concepts of computer-based
screening for adolescents have been
introduced successfully, using non-physician
health counselors,32,33 and have proved to
be faceable, economical and acceptable
alternative to traditional clinical practice
for screening young people for health-
compromising behaviors and providing
individualized health education and routine
physical examinations. This model would
likely increase adolescents' access to needed
preventive services at a very modest cost.
Goals of Counseling
™™ Resolution of problems
™™ Improved personal effectiveness
™™ Decision-making, avoiding impulsive
actions, reducing possibility of error
™™ Modification of behavior, removal of
undesired behavior
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™™ Promoting mental health
™™ Improving scholastic performance
™™ Proper follow-up.
Improving Existing Services—
Adolescent Care Clinics (Acc)
Adolescence being the tender and most
vulnerable stage in life, it demands special
attention. Hence, a common platform where all
adolescents can come together and share their
views and ambitions is the need of the hour.
The objectives and guidelines for ACC
are in tune with the recommendations of the
American Medical Association's Department
of Adolescent Health, and endorsed by the
American Academy of Family Physicians’
Association, in their document titled
“Guidelines for Adolescent Preventive Services
(GAPS)”34
Objectives
™™ To make adolescents aware about the need
for taking care their health and positive
health development concepts
™™ To introduce health cards to adolescents.
Monthly health check up can be conducted
to create a sense of health consciousness
and to ensure positive health attitude
among adolescents
™™ To identify scholastic and behavioural
problems among students and to render
appropriate services
™™ To take height, weight measurements and
detailed hearing and visual assessment
™™ To deal with psychological problems.
Guidelines for ACC
™™ ACC should be adolescent friendly
™™ Weekends may be more ideal for ACC
™™ ACC may be conducted at clinic, hospital,
school or Teen clubs.
™™ Age 10 and 19 years should be the only
criteria for availing services.

™™ Boys and girls above 10 years, reporting to
family/pediatric outpatient for any illness
should have followed up at ACC.
™™ The family physician/pediatrician who
has been looking after the child is the ideal
ACCC physician and family counselor.
™™ Adolescents need privacy to open up
™™ Physicians may be more comfortable
examining adolescent girls in the presence
of their mothers.
™™ Part time services of a gynecologist,
psychologist, psychiatrist, dermatologist,
cosmetologist, etc. may be ideal.
™™ Create a team of adolescent friendly doctors
and well-wishers in the community.
Conclusion
Adolescence is a phase of intense change and
throws up in its wake a gamut of problems not
found in any other age group. Parents, elders,
family dynamics, teachers, and friends play a
vital role in modulating adolescent personality
and behaviour. Customized consultations,
communications, and counseling skills
are the cornerstone of the assessment and
management of adolescent problems.
Existing adolescent care should preferably
be decentralized with due recognition to local
cultures and the need to maximize community
participation.
Family physicians occupy a central role,
balancing adolescents’ aspirations at one end
and the realities of the world at the other.
References
1. Youth and Adolescents in a World of 7 Billion.
Web site - http://www.unfpa.org/public/
home/news/pid/7971. Accessed on 03-12-11.
2. Barton Joanne et al. Adolescence. In: The
Oxford TB of Public Health, 4th ed, 2002.p.1623.
3. Ferreira MM, et al. Life styles in adolescence:
sexual behavior of Portuguese adolescents.Rev
Esc Enferm USP, 2011;45(3):589–95. [PMID:
21710062: Abstract].
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4. Staton M, et al. Risky sex behavior and substance
use among young adults.Health Soc Work.
1999;24(2):147–54. [PMID: 10340165: Abstract].
5. Melzer-Lange MD. Violence and associated
high-risk health behavior in adolescents.
Substance abuse, sexually transmitted
diseases, and pregnancy of adolescents.
Pediatr Clin North Am, 1998;45(2):307–17.
[PMID: 9568011: Abstract].
6. Middleman AB, et al. Anabolic steroid use and
associated health risk behaviours. Sports Med,
1996;21(4):251–5. [PMID: 8726343; Abstract].
7. Levine DA. Need for services in a new urban
teenage clinic for men. J Natl Med Assoc,
2000; 92(1):42–5. [PMID: 10800287: Free PMC
Article].
8. WHO web site - http://www.who.int/features/
factfiles/adolescent_health/facts/en/index9.
html. Accessed on 05-12-11.
9. Committee on Adolescence American
Academy of Pediatrics. Achieving quality
health services for adolescents. Pediatrics,
2008;121(6):1263–70. [PMID: 18519499: Free
Article].
10. Telfair J, et al. Quality health care for adolescents
with special health-care needs: issues and
clinical implications.J Pediatr Nurs, 2005;
20(1):15–24. [PMID: 15834355: Abstract].
11. McPherson Ann. ABC of adolescence -
Adolescents in primary care. BMJ, 2005; 330:
465–67
12. Adolescent Health Committee(2002–2003).
Age limits and adolescents. Paediatr Child
Health, 2003;8(9):577.
13. Irwin CE Jr, et al. Appointment-keeping
behavior in adolescents. J Pediatr, 1981;
99(5):799–802. [PMID: 7299561: Abstract].
14. Litt IF, et al. Satisfaction with health care. A
predictor of adolescents’ appointment keeping.
J Adolesc Health Care, 1984;5(3):196–200.
[PMID: 6735836: Abstract].
15. Irwin CE Jr, et al. Appointment-keeping
behavior in adolescents: factors associated with
follow-up appointment-keeping. Pediatrics,
1993;92(1):20–3. [PMID: 8516080: Abstract].
16. Thrall JS, et al. Confidentiality and adolescents’
use of providers for health information and
for pelvic examinations. Arch Pediatr Adolesc
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Med, 2000;154(9):885–92. [PMID: 10980791:
Free Article].
17. Hutchinson JW, et al. Changing parental
opinions about teen privac y through
education. Pediatrics, 2005;116(4):966–71.
[PMID: 16199709: Free Article].
18. H. Verdain Barnes. The adolescent patient,
Chapter 223. In: H Kenneth Walker et al. (Eds).
Clinical Methods, 3rd edn. Emory University
School of Medicine, Atlanta, Georgia, Boston:
Butterworths; 1990.
19. Warrell DA, et al. Oxford TB of Medicine. Vol.
III 4th ed.: 1372.
20. Ste i n b e rg L . Co g n i t i ve a n d a f f e c t ive
development in adolescence. Trends Cogn Sci.
2005;9(2):69-74. [PMID: 15668099: Abstract].
21. Romeo RD. Adolescence: a central event in
shaping stress reactivity. Dev Psychobiol,
2010;52(3):244-53. [PMID: 20175102: Abstract].
22. Harikumar SK. Counseling for youth. J of
Teenage care and premarital counseling, 2002;
2(8&9):24.
23. Ma J, et al . U.S. adolescents receive suboptimal
preventive counseling during ambulatory
care. J Adolesc Health, 2005;36(5):441. [PMID:
15841517: Abstract].
24. Klein JD, et al. improving adolescent preventive
care in community health centers. Pediatrics,
2001;107(2):318-27. [PMID: 11158465:
Abstract].
25. Ozer EM, et al. Can it be done? Implementing
adolescent clinical preventive services. Health
Serv Res, 2001;36(6 Pt 2):150-65. [PMID:
16148966: Free PMC Article].
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26. Klein JD, et al. Improving adolescent health
outcomes. Minerva Pediatr, 2002;54(1):25-39.
[PMID: 11862164: Abstract].
27. Montalto NJ. Implementing the guidelines
for adolescent preventive services. Am Fam
Physician, 1998;57(9):2181-8, 2189-90. [PMID:
9606308: Free Article].
28. Knishkowy B, et al. GAPS (AMA Guidelines
for Adolescent Preventive Services). Where
are the gaps? Arch Pediatr Adolesc Med, 1997;
151(2):123-8.[PMID:9041865: Abstract].
29. W e b s i t e h t t p : / / w w w .
uspreventiveservicestaskforce.org/tfchildcat.
htm (Accessed on 20-12-11).
30. Hedberg VA, et al. Health counseling in
adolescent preventive visits: effectiveness,
current practices, and quality measurement.
J Adolesc Health, 1998;23(6):344-53. [PMID:
9870328: Abstract].
31. Mangione-Smith R, et al. Assessing the quality
of healthcare provided to children.Health Serv
Res, 1998;33(4 Pt 2):1059-90. [PMID: 9776949:
Free PMC Article].
32. Paperny DM, et al. Computer-assisted
health counselor visits: a low-cost model for
comprehensive adolescent preventive services.
Arch Pediatr Adolesc Med, 1999;153(1):63-7.
33. Paperny DM. Computerized health assessment
and education for adolescent HIV and STD
prevention in health care settings and schools.
Health Educ Behav, 1997;24(1):54-70. [PMID:
9112098: Abstract].
34. Montalto Norman J. Guidelines for Adolescent
Preventive Services (GAPS); Am Academy of
Fam Phy, 1998.
 25 A problem adolescent

“The main problem with teenagers is that they are just like their parents were at their age.”

Introduction of adolescents, adolescence still represents the

Few periods of human development are so
distinctly marked by changes in maturation
as in adolescence—that time of dramatic
and rapid physical, psychosocial, moral, and
cognitive growth. Hall depicted adolescence
as a tumultuous period, a havoc caused by the
“raging hormones” brought about by puberty.1
Growth spurt occurs, secondary sexual
characteristics appear, fertility is achieved,
and profound psychological changes take
place. The adolescent is rich in knowledgeable
spheres such as memory, perceiving things,
concept formation, association, generalization,
imagination and decision-making.
However, adolescent risk taking has
emerged as a leading public health concern.
High-risk activities in adolescence—
unprotected sex, substance abuse, violence,
and other forms of risky behavior—remain a
pervasive and costly problem in our societies,
despite extensive efforts to prevent or reduce
these activities through intervention programs.
Parenting Stress
Although most adolescents live a life with few
serious personal or social problems, for a minority
most troubling years. The nature and pace of
these changes may be stressful not only for the
adolescent, but for his/her family. Research has
suggested an association between “parenting
stress” and childhood externalizing behavior
problems. i.e., parenting stress is increased
when children behave badly. Parenting stress
also appears to exacerbate children’s problem
behaviors. Parental stress seems to increase
parent irritability, influence their disciplinary
practices and increase the likelihood that parents
initiate or maintain aversive interchanges or
counterattack in response to child aggression.
Parents experiencing high levels of stress are
likely to pay more attention to negative behavior
and attribute them to the child rather than to the
situation. These factors seem to directly promote
or mediate the aggression and oppositional
behavior in children.2,3
Parenting Style and Problem
Adolescent*
Adolescents often struggle being dependent on
their parents while having a strong desire to be
independent. They may also feel overwhelmed
by the emotional and physical changes they
are going through.

*Three different parenting styles have been formulated by a famous psychologist Diana Baumrind in the
1960s and are today known as the “patenting styles”: the authoritarian parenting style, the permissive
parenting style, and the authoritative parenting style; and the later added, neglectful parenting style.(Ref.
web site - http://www.positive-parenting-ally.com/3-parenting-styles.html)

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 234  Section 5: Adolescent Health
At the same time, adolescents may be
facing many pressures — from friends to fit in
and from parents and other adults to do well
in school, or activities like sports, and on many
occasions a part-time job too.
Authoritative parenting style*: When parents
are caring and loving, give a sense of security
and permit adolescents to handle their own
affairs within reasonable boundaries, without
being over-indulgent and demanding, it is
easier for the adolescent to cope up with the
problems (Table 25.1). Adolescents whose
parents convey clear expectations regarding
their children’s behavior and show consistent
limit setting and monitoring are less likely to
engage in risky behaviors. In such a scenario,
parents are considerate, reasonable and
consistent while dealing with their adolescents.
Permissive parenting style**: If parents are
not reasonable and understanding, or the
child is being brought up by a single parent
with disturbed family dynamics, the child
may show signs of behavior disorders.
Studies to investigate the correlation between
behavioral problems and single parenting,
family communications and medical care
delivery show that single-parent homes
had a 3-fold higher incidence of behavioral
problems, a greater degree of communication
and a lower use of community resources than
two-parent families. 4 Parents themselves
can sometimes unknowingly make things
worse by giving too little attention to good
behavior, always being too quick to criticise,
or by being too flexible about the rules and
Table 25.1  What an adolescent expects from parents
• Parental help and interest: Parent’s willingness
and to take interest in the adolescent’s activities,
friends and their parents and the problems the
adolescents face; their willingness to backup
wherever necessary gives the adolescents a
feeling of being loved.
• Listening, understanding and talking: Adolescents
expect their parents to listen to their ideas and
accept their opinions as relevant. Adolescents
value sympathetic, understanding parents who
feel that their child has something important to
say and are willing to communicate with their
adolescents freely.
• Love and acceptance: Parents are expected to
express their love in words and actions and show
it subtly by accepting whatever he or she is, with
their mistakes and their problems.
• Trust: Adolescents get a feeling of being respected
and loved when their parents trust them.
• Autonomy: Adolescents aspire to be treated as
independent individuals. Parents should give
them freedom in gradually increasing measures.
not supervising their children adequately.
This often happens if a parent is depressed,
exhausted or overwhelmed.
If corrective measures are not instituted at
appropriate stages by the parents or elders, e.g.
by advocating permissive parenting style, the
child grows up as an amateurish adolescent,
experiencing futility. Many adolescents feel
inadequate, impersonalized and alienated.
Such a disturbed or distressed adolescent
may be labeled as a “problem adolescent”
by the parents or teachers. As the parents are
emotionally close to adolescents, they are the
ones who can detect the earliest indications of
disturbed adolescents.

*Authoritative parents reflects a balance between two values - freedom and responsibility; and emphasize
setting high standards, being nurturing and responsive, and showing respect for children as independent,
rational beings. The authoritative parent expects maturity and cooperation, and offers children lots of
emotional support.
**Permissive parenting style: Parents strive to accept and meet as many of the child’s needs and desires as
possible; parents don’t have high expectations of behavioral standards. Rather than being a parent who
tries to shape and mold his/her child according to set standards via control measures, the permissive
parent’s goal is to be available whenever the child needs it.

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Behavior Problems
Behavioral problems can occur in adolescents
of all ages. Generally, mundane issues such
as confrontation with parents, disobeying
parent’s advise, an occasional violent reaction
or tantrums, breaking and spoiling things are a
common occurrence in any family. However,
parents and physicians must distinguish
occasional errors of judgment from a degree
of misbehavior that requires professional
intervention. If adolescents are repeatedly
being disobedient and aggressive, and their
behavior is out of the ordinary, and seriously
break the rules accepted in their family and
community (Table 25.2), this is much more
than ordinary childish mischief or adolescent
rebelliousness.
Table 25.2  Rules and behavior
• Set clear and reasonable limits: Communicate
traditional family rules to teens; make them aware
of the consequences of frequent disobeying family
rules – its nature and severity.
• Enforce the rules consistently: Parents should do
everything possible to make sure that they are in
agreement about rules and consequences. Teens
are experts on manipulation when they sense
there is disagreement on an issue and possess
skills to get what they want from others.
• Let teens experience the consequences of
their behavior within reasonable safety limits:
Consequences like missing assignments, being
late for school or writing apologize to others when
appropriate can prove valuable learning experiences
for your teen. But don’t compromise safety.
• Voice your concern when teens’ behavior is
objectionable: How issues such as smoking,
alcohol and drug use, sexual activity, violence,
harassment of others and destruction of property
affect their lives must be explained.
• Let your teen know there is parental support no
matter what happens—then follow through: If they
break the law or cause harm to another person or
property they will have to face the consequences
of their actions, but need not fear they will “lose”
their parent as a result.
• Grant independence in stages: Parents should
expand a teen’s rights and responsibilities gradually
over time. By demonstrating trustworthiness,
teens will have a personal stake in establishing
what they are allowed or not allowed to do.
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Chapter 25: A Problem Adolescent 235
Before adolescents experience distress
and show disturbed behavior, they are likely
to show some indications of disturbed mind
through their behavior, which may present
themselves in the following manner:
™™ Behavior changes:
ƒƒ Agitated or restless behavior
ƒƒ Weight loss or gain
ƒƒ Trouble concentrating
ƒƒ Ongoing feelings of sadness
ƒƒ Not caring about people and routine
work
ƒƒ Lack of motivation
ƒƒ Fatigue, loss of energy and lack of
interest in activities
ƒƒ Low self-esteem
ƒƒ Trouble falling asleep
™™ Addictions—alcohol, drugs
™™ Academic—drop in grade
™™ Organic problems—bed-wetting, stam­
mering, stuttering, encopresis
ƒƒ Neurotic problems—hysterical symp­
toms, depression, anorexia nervosa
ƒƒ Antisocial problems—violence, van­
dalism, sex crimes
ƒƒ Legal—involvement or clash with laws
Adolescent Depression
True depression in teens is often difficult to
diagnose, because normal teenagers have
up and down moods. Their moods may go
back and forth over a period of hours or days.
Also, symptoms of depression in adolescents
(Table 25.3) may not be the same as in adult
depression. An astute watch by parents, elders
and teachers is essential for changes in school
work, sleep, and behavior to detect and treat
adolescent depression.
Depression can be a response to many
situations and stresses. In teenagers, depressed
mood is common because of:
™™ Biological factors: Normal process of
maturing, influence of “raging hormones”,
 236  Section 5: Adolescent Health
Table 25.3  Depression symptoms in adolescents self-esteem and self-confidence. Emotional
• Depressed humor pain arises if these psychological needs are not
• Difficulty in concentrating met. When such pain becomes unbearable and
• Feelings of hopelessness and/or guilt
• Irritability and instability overwhelming with no way out, they may choose
• Isolation the option of ending their lives by suicide (Flow
• Lack of motivation and a significant lack of interest chart 25.1). There are usually more than one
• Loss of energy
• Low self-esteem
reason for ending their lives. Suicide is most
• Poor school performance commonly understood as a desperate act to
• Psychomotor retardation avoid the pain of living as much as it is an effort
• Severe behavioral problems
to seek death. The “suicide attempt”**, whether
• Sleep disorders
• Suicidal ideas and attempts successful or not, is a communication of that
emotional pain.
™™ Family dynamics: Conflicts with parents, Suicide is one of the top three causes
poor parenting or caregiving, loss of a of death between ages 15 and 24 years in
parent to death or divorce, authoritarian developed countries, surpassed only by
parenting style, homicide and accidents.5 The two major risk
™™ Social factors: Death of a friend or relative, factors for adolescent suicide are conflict
breakup with a boyfriend or girlfriend, with parents and an undiagnosed psychiatric
™™ Academics: Failure at school, bullying or Flow chart 25.1  Pathway to suicide
harassment at school or somewhere else,
™™ Personality traits: Low self-esteem or
being overly dependent, self-critical or
pessimistic, obesity,
™™ Chronic illness: Asthma, diabetes, anxiety
disorders,
™™ Substance use and abuse: alcohol, nicotine
and other drugs, and
™™ Child abuse: Both physical and sexual.
A severely depressed adolescent* may require
psychiatric help. If not helped, the adolescent
may indulge in destructive behavior, including
suicide.

Suicidal Risk
All adolescents have emotional or psychological
needs which include the needs for love,
acceptance, praise, recognition, companionship, Source: http://www.searo.who.int/en/Section1174/Section1199/
sense of achievement and success, responsibility, Section1567/Section1824_8080.htm Accessed on 07-01-12.

*For details of “Diagnostic criteria for primary DSM-IV depression disorders in children and adolescents”:
ref. web site - < http://www.ncbi.nlm.nih.gov/books/NBK35129/>.
**The term ‘attempted suicide’ is potentially misleading in that the majority of patients are not unequivocally
trying to kill themselves. The preferred term is “DSH-deliberate self-harm-”.(Ref. Davidson’s Prin. and
Pract.of Med. 19th edn. p. 252)

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disorder such as depression, bipolar disorder,
and drug addiction, especially when combined
with another mental health disorder.6
Adolescents with previous suicidal
behavior—a history of previous suicide
attempts, explicit statement of suicidal ideas
or feelings, such as, “I want to go to sleep and
never wake up”, or “I’m going away and you
won’t have to worry about me anymore” —
are at increased risk for subsequent suicide
attempts. Factors related to family adversity,
social alienation and precipitating problems
also contribute to the risk of suicide.7 Evidence
indicate that, in general, adolescents from
one parent and stepparent families reported
lower self-esteem, more symptoms of anxiety
and loneliness, more depressed mood, more
suicidal thoughts and more suicide attempts
than children from intact families.8
Because most patients seek some form of
medical help, including their family physicians,
within a month of their suicide, recognition
and treatment of depression is a promising
way to prevent suicide.
According to the National Mental
Health Association, four of five teens who
kill themselves have given a clear warning
of their intentions. Parents and friends
should recognize these behaviors commonly
associated with suicide.
Although it is difficult to accurately predict
which persons with these risk factors will
ultimately commit suicide, there are some
possible indicators of disturbed adolescent
that may lead to suicide. Research has
demonstrated that it is possible to identify
such “high-risk adolescents” if one is sensitive
and open to words, actions and signals such as:
™™ Persistently depressed or disappointed
mood
*An exhaustive information about the role of health professionals, community, federal governments, etc. in
suicide prevention is available at the web site – < http://www.searo.who.int/en/section1174/section1199/
section1567_6745.htm>.
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Chapter 25: A Problem Adolescent 237
™™ Breakdown in communication with
parents, friends, and other important
persons around
™™ Statements like ‘I wish I was dead’, ‘ what is
there to live for’
™™ Enquiries about lethal properties of drugs
™™ Increasingly social isolation and withdrawal
™™ Any obvious stress event, such as failure in
examination, breakup of a love affair, death
of a near one
™™ Self-destructive behavior, e.g. reckless
driving, alcohol/drug abuse
™™ Declining school performance
™™ Firearms in the home
™™ Attempts at suicide.
Physician’s Role*
If family physicians have been attending
to adolescents, they have the immense
advantage of the rapport and the goodwill
already established over the years. They have
the parents’ trust, insight into family and local
community, and essential general medical
knowledge about management of mental
health problems in this age group.9,10
Most adolescents presenting with “suicide
attempts” should be offered outpatient
treatment. This takes the form of brief individual
therapy and family therapy. Individual therapy
aims to improve their capacity to solve problems
and handle stress in a more adaptive way. A
family approach is often indicated to improve
the relationship and communication between
the adolescents and the parents so as to enable
the parents to understand and support the
adolescents in distress. If the suicide risk is high
and a major psychiatric disorder is present, the
patient should be admitted to a hospital for
further treatment.
 238  Section 5: Adolescent Health
Following principles and strategies are
helpful in dealing with problem adolescents:
™™ In the evaluation of every depressed
adolescent, consider suicide
™™ Interrogate the parents individually and
adolescent separately
™™ The choice of the presence of the parents,
when adolescent is being interviewed,
should be left to the adolescent
™™ Establish a trusting relationship with
adolescent and parents
™™ During the interrogation be alert to
note the troubled spots or events in the
psychosocial environment, especially
related to family matters
™™ Interrogation should also include school/
teacher impressions and circle of friends
™™ After identifying the causal factors, the
parents need to be counseled on the
problems of the adolescent and corrective
measure initiated
™™ Psychiatr ic disorders do occur in
adolescents, and they should be rightly
diagnosed. They should not be confused
with ‘just growing problems’ or written off
as “adolescent turmoil”
™™ In mild to moderate cases, pharmaco­
therapy, coupled with behavioral therapy,
can be initiated
™™ Ensure regular follow-up.
Indications for Psychiatric
Referral11
Commonly, a referral should be strongly
considered if the adolescent is not behaving
or functioning in a manner characteristic
of his/her age group. Following are strong
indications for psychiatric referral:
™™ Active suicidal thoughts
™™ Drug/alcohol abuse
™™ Violent, destructive behavior
™™ Persistent somatic complaints with no
evidence of organic pathology
™™ School truant.
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In general, health professionals should be in
close touch with the community in order to know
the people better and to be able to intervene
in a variety of action-oriented programmes.
Due to their involvement in health matters
and their unique and respected stature, health
professionals can offer and deliver a wide range
of services to people with suicidal thoughts and
behavior, and to those families with a history of
suicide among its members.
Increasingly, Internet-based information
and interventions are being used to engage
young people in the help-seeking process.
“Reach Out”—a national Internet-based
mental health service for young people—
plays a role in the prevention of mental
health problems by: facilitating help-seeking
and connecting young people with services,
such as general practitioners, and allied and
mental health professionals in their local
communities; and providing opportunities
for all young people to develop the skills and
capacity to better understand mental health
difficulties and manage adversity, thereby
complementing traditional support.12,13
A Scheme for Fortifying the Parent-
Adolescent Relationship
Teach “parents” about adolescent development:
™™ Offer guidance about physical and
psychosocial changes of adolescence, and
when they occur.
™™ Increase sensitivity to the adolescent’s
needs by having parents reflect on their
own adolescence.
™™ Correct parents’ negative perceptions of
normal adolescent changes.
Teach “teenagers” about adolescent development:
™™ Offer guidance about physical and
psychosocial changes of adolescence, and
when they occur.
™™ Encourage a discussion about development
by normalizing probable curiosity.

™™ Provide verbal and written information
(such as pamphlets) about development.
Teach “parents and teenagers” to communicate
with each other:
™™ Teach parents to be good listeners. Instruct
them to listen to the adolescent’s concerns
calmly and nonjudgmentally.
™™ Demonstrate how parents can facilitate
conversations with the adolescent.
Encourage parents to use nonthreatening,
open-ended questions.
™™ Discourage counterproductive communi­
cation, such as lecturing, preaching,
accusatory remarks, and distracting
nonverbal behaviors.
™™ Encourage parents and teenagers to set
aside a time regularly to discuss family
issues and build communication skills.
Guidance and Counseling to
Parents
™™ As far as possible, parents should not be
blamed or labeled guilty for the behavior
of the adolescent. They should be made to
understand and assured that adolescents
have behavioral difficulties, causing stress
and anxiety in them.
™™ Reinforce positive qualities of the
adolescents. Every adolescent has some
strength or positive points in his/her
personality, which should be reinforced by
appreciating or rewarding them.
™™ Explain difficulties. The difficulties
experienced by the adolescents in
behaviour adjustments must be explained
to the parents. Suitable remedial measures
should be discussed to achieve desired
outcome.
™™ Focus on expectations of the adolescents
from their parents. This will help the parents
to understand their own behaviour, which
might have disturbed their adolescent.
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Chapter 25: A Problem Adolescent 239
Preventive Advice to Parents and
Family Members14
™™ Don’t brush off a suicide threat. Draw the
teenager in. Surround him or her with love
and reassurance that they are suffering
from depression, which can be treated
medically.
™™ Make sure that the adolescent realizes that
there are people who want to help. Mention
teachers, school counselors, parents of
friends, trusted family members, priest,
etc. — whatever it takes to persuade them
that they have someone to share their
feelings with.
™™ Seek professional help immediately. Start
with your family physician. They usually
have resources you can contact.
™™ Do not leave the adolescents alone if you
have a “gut feeling” that he/she is desperate.
™™ Please remember that depression is an
illness, which can be treated, usually
very effectively. There is no stigma, and it
doesn’t mean there’s no hope.
™™ If you have firearms in your home please
safeguard them so that the guns and
ammunition are totally inaccessible to
your children.
™™ If there is a news item or newspaper article
dealing with a local suicide, don’t be
afraid to discuss it with your adolescents.
Bringing the subject up, and out into the
open, does not “give adolescents ideas”.
Rather, it opens a line of communication
so that you have an opportunity to discuss
alternatives to suicide and to make sure
that your adolescent knows that he/she
can come to you in case they are feeling
depressed or having suicidal thoughts.
Conclusion
Adolescence is a time of change. During
a d o l e s c e n c e t e e n s e x p e r i e n c e rap i d
physical, social, emotional, and intellectual
 240  Section 5: Adolescent Health
development.The assessment of stressful life
events during adolescence is important for
both parents and physicians. Depression and
undiagnosed psychological problems are the
commonest aetiological factors for distress,
leading to a “problem adolescent”. Problems
may arise because parents do not change their
parenting style. Physicians play a pivotal role
in making the parents aware of ideal ways of
parenting. Due to their involvement in health
matters and their unique and respected
stature, physicians can offer and deliver a wide
range of services to families with a history of a
problem adolescent.
References
1. Hall GS. Adolescence. New York: Appleton,
1904.
2. Morgan J, et al. Parenting stress and
externalizing behavior: Research Review. Child
and Family Social Work, 2002;7:219–25.
3. McCarty, et al. Conduct Problems Prevention
Research Group. Mediators of the relation
between maternal depressive symptoms and
child internalizing and disruptive behavior
disorders. Journal of Family Psychology, 2003;
17(4):545–56.
4. Hawley LE, et al. Resident and parental
perceptions of adolescent problems and family
communications in a low socioeconomic
population. J Fam Pract, 1984;19(5):651–5.
[PMID: 6491630: Abstract].
5. http://www.nlm.nih.gov/medlineplus/ency/
article/001915.htm
mebooksfree.com
6. Sourander A, et al. Childhood predictors
of completed and severe suicide attempts:
findings from the Finnish 1981 Birth Cohort
Study. Arch Gen Psychiatry, 2009;66(4):398–
406. [PMID: 19349309: Free Article].
7. Pelkonen M, et al. Child and adolescent suicide:
epidemiology, risk factors, and approaches to
prevention. Paediatr Drugs, 2003;5(4):243–65.
[PMID: 12662120: Abstract].
8. Garnefski N, et al. Adolescents from one parent,
stepparent and intact families: emotional
problems and suicide attempts. J Adolesc,
1997;20(2):201-8. [PMID: 9104655: Abstract].
9. Lykke K, et al. “This is not normal ... “--signs
that make the GP question the child’s well-
being. Fam Pract, 2008;25(3):146–53. Epub
2008 May 30. [PMID: 18515812: Free Article].
10. Hafting M, et al. “You may wade through them
without seeing them”: general practitioners
and their young patients with mental health
problems. Nord J Psychiatry, 2009;63(3):256–9.
[PMID: 19391060: Abstract].
11. Kisely S, et al. Collaboration between primary
care and psychiatric services: does it help family
physicians? Can Fam Physician, 2006; 52:876–7.
[PMID: 17273487: Free PMC Article].
12. Burns J, et al. Reach Out! Innovation in service
delivery. Med J Aust, 2007;187(7 Suppl):S31–4.
[PMID: 17908022: Free Article].
13. Web site < http://www.reachoutuk.org/HTML/
index.html> Accessed on 07-01–12.
14. Beardslee WR, et al. A family-based approach
to the prevention of depressive symptoms
in children at risk: evidence of parental and
child change. Pediatrics, 2003;112(2):e119-31.
[PMID: 12897317: Free Article].
 6
Section

Geriatric Health
™™ Aging and Geriatric Concepts
™™ Comprehensive Geriatric Assessment
™™ Management of Common Geriatric Problems
™™ Practical Prescribing to the Elderly

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 26 Aging and
Geriatric Concepts

“Old age is a temporary inconvenience, destined to be banished in the next century.”

Introduction used as a basis for decision-making in terms of

Aging, in the sense of senescence, is a progressive
loss of adaptability of an individual organism
as time passes. Aging can also be defined as
a progressive functional decline or a gradual
deterioration of physiological function with age,
or the intrinsic, inevitable, and irreversible age-
related process of loss of viability and increase
in vulnerability.1 As individuals grow older, the
homeostatic mechanisms on which survival
depends become on average less sensitive,
slower, less accurate, and less well sustained.
This decline (referred to as “homeostenosis”), is
usually evident by the third decade and is gradual
and progressive, although the rate and extent
of decline vary.2 Each organ system’s decline is
largely independent of changes in other organ
systems, and is influenced by interactions
between intrinsic, genetically determined
factors and extrinsic factors in lifestyle and
environment.* The terms “chronological”**
and “biological”*** aging have been coined to
try to define such differences, and increasingly
“biological” rather than “chronological” age is
investigations and interventions.3
Definition
The word “Geriatrics” was derived from the
Greek word “geras”, meaning old age, and
“iatrike” meaning medical treatment. Nascher
coined it in 1909.****4 Nascher suggests that
geriatrics deals with what he refers to as the
senile state, rather than years of life.
Unlike specialties like cardiology and
neurology, geriatrics does not deal with a group
of diseases or organs. The British Geriatric
Society has defined “Geriatrics” as: “that branch
of general medicine concerned with the clinical,
preventive, remedial and social aspects of
illness in older people”, and the goal of geriatric
care is “to restore an ill and disabled person
to a level of maximum ability and wherever
possible return the person to an independent
life at home.”5 The wide definition necessarily
implies that geriatric care must be delivered
in both hospitals and community, requires
a multidisciplinary approach and shares

*“Some are aged before they are old, some are old but are not aged.” … Mark Twine
**Age determined by the passage of time since birth.
***Age determined by physiological parameters, e.g. physical structure of the body as well as changes in
the performance of motor skills and sensory awareness.
****Ignatz Leo Nascher, MD, (1863–1944) New York physician, was the first modern American geriatrician.
He is the author of many articles on geriatrics and edited a book entitled Geriatrics: The Diseases of Old
Age and Their Treatment.

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 244  Section 6: Geriatric Health
overlapping philosophies with preventive, decline and rising life expectancy. Whereas the
rehabilitation, palliative and family medicine. number of persons aged 60 or over is expected
The specialty of geriatric medicine, i.e. to triple,** that of persons aged 80 years or
“gerontology”*, is defined less in terms of the over—usually termed as the “oldest-old”—is
diseases it treats, rather than in the range of projected to increase four-fold, to reach 395
responsibility it accepts. This responsibility million in 2050. Today, just about half of the
embraces preventive care, health promotion, oldest-old live in developing countries, but that
diagnosis, and treatment of acute illness, followed share is expected to reach 69% in 2050. Further,
by rehabilitation of patients in the community. 65% of the world’s older persons already live
in the less developed regions, and by 2050
Demographic Revolution nearly 80% will do so. While population aging
is less advanced in developing countries,
Due to rapid industrialization, urbanization,
the population of majority of them is poised
and advanced healthcare delivery system,
to enter a period of rapid population aging,
there is no denying the fact that health status of
increasing by more than five-fold in developing
both the developed and developing countries
countries, compared to slightly more than two-
has vastly improved, resulting in increased life
fold in developed countries. In developed
span of its individuals (Table 26.1). Globally,
countries as a whole, the number of older
the number of persons aged 60 years or over—
persons has already surpassed the number of
usually termed as “elderly”—is expected to
children (persons under age 15 years), and by
almost triple, increasing from 739 million in
2050 the number of older persons in developed
2009 to 2 billion by 2050 as a result of fertility
countries will be more than twice the number
of children.6
Table 26.1  Ageing scenario in India: Population
60 years or over
1901 12 millions
The Role of Family Physician
1961 24 millions Presently, as the fastest growing segment of
1991 56 millions
the population is 60 years, and the number of
“oldest-old” is increasing at an even faster rate,
2001 70 millions
many of our patients are “frail”***, needing not
2010 115 millions
only astute medical diagnosis and treatment,
2025 133 millions
but also interventions which address physical
Projected figure
and mental functioning. Therefore, the elderly
Life expectancy at birth
require special care. But “the fact remains that
1901 24 years
the government infrastructure is grossly falling
1991 55 years short, and hence the onus of health care is
2010 66.6 Male falling on the private sector; be it hospitals,
67.8 Female
nursing homes or family physicians.”7 Besides,
2025 70.5 Male most hospitals do not have a special geriatric
Projected figure 73.3 Female
facility and if there is one, it is prohibitively

*Multi- disciplinary study of the phenomena and problems of ageing.

**Every 8 seconds…a Baby Boomer turns 60…! (Ref. The American Geriatrics Society)
***The clinical phenotype of frailty manifests as multi-system pathologies characterized by low physical
activity, global weakness with low muscle strength, fatigability/exhaustion, overall slowness particularly
of gait, loss of weight among others.

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 Chapter 26: Aging and Geriatric Concepts 245
expensive. To correct this imbalance, the
principles of health economics suggest that the
elderly requiring treatment for longer periods
are best kept at home for better resource
utilization. Further, “the principle focus of
WHO activities has been on the community
participation and family care. Promotion of
traditional family ties has, therefore, been
underscored as compared to institutional care.
Making optimum use of the available primary
healthcare services is the cornerstone for
supporting traditional family care.”8 ,9
This change in the demographic scenario,
with its wide-ranging socioeconomic
ramifications, elder patients constitute
a significantly large proportion in family
practice. 10 We, as family physicians, must
realize that our elderly patients need more
than just medications and counseling to
help them cope up with the aging process.
Therefore, we need the knowledge and the
skills to provide competent professional care
and services to the elderly so that they can
lead a life as comfortable and independent as
possible in the community.11
Characteristics of Disease in
Elderly
There are differences of emphasis in the
approach to the elderly as compared with
young people, and in particular, it may be
entirely non-specific.
Nonspecific Presentation of Illness
Typical or specific signs and symptoms that
point to a specific diagnosis may be absent.
For example:
™™ Silent myocardial infarction: Myocardial
infarction occurs quite commonly in the
elderly but is usually not accompanied
by typical chest pain. Often the pain is
totally absent and the patient presents
with an episode of collapse, confusion, or
breathlessness.
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™™ Chest infection without cough or sputum: In
the old, lobar pneumonia, instead of having
its presence indicated by cough, fever, and
leukocytosis, as in the young, may present
insidiously with slight breathlessness or
unproductive cough.
™™ Acute abdomen may have “silent”
presentation; only mild vague abdominal
pain, constipation, or mild breathlessness
may be the presenting symptoms.
™™ Thyroid disease: An elderly with
hyperthyroidism may not have goiter,
tremor, exophthalmus, but may present
with atrial fibrillation, confusion, syncope,
and weakness.
™™ Diabetes is easily missed, as glycosuria may
not occur owing to high renal threshold;
a random blood sugar measurement is a
more reliable screening test.
™™ Parkinsonism is often overlooked, being
common in old age but missed because
the tremor is either absent or slight and the
typical rigidity may not be noticed.
™™ Malignancy: Poorly localized skeletal
and muscular aches and pains that are
generally attributed to “rheumatism”
can be due to osteomalacia, metastasis
in bones from breast or prostate. Silent
masses of the bowel, especially those from
the ascending colon, may exist without
major symptoms due to reduced neuronal
sensitivity in the GI tract.
™™ Falls and Blackouts: This is an important
presentation of illness in the elderly.
Pa t i e n t s w i t h Pa r k i n s o n i s m a n d
osteoarthritis are particularly prone to
repeated falls. Patients with rheumatoid
arthritis affecting the cervical spine
may have falls owing to vertebra-basilar
insufficiency which occurs on moving
the neck. The side effects of drugs e.g.
anti-hypertensives, diuretics and tricyclic
antidepressants may result in falls due to
postural hypotension.
 246  Section 6: Geriatric Health
™™ Iatrogenic illness: These illnesses should
always be considered. The elderly are
particularly vulnerable to the adverse
effects of drugs, such as drug-induced
Parkinsonism from phenothiazines,
weakness due to hypokalemia following
diuretic therapy with inadequate potassium
supplementation, and depression from
reserpine containing drugs sedatives and
tranquilizers.
Thus, the non-specific presentation of illness
in the old should never be dismissed as due to
“ageism”, “senility” or some other vague label
applied to them. Many opportunities for effective
treatment of old patients can be missed by the
traditional approach to diagnosis, at the cost of
unnecessary suffering and disability.
In the elderly, a comprehensive review of
medical history, functional history (activities
of daily life), along with a detailed review of all
medications, and targeted investigations will
often reveal the underlying cause or “hidden
illness” (Table 26.2) and treatment of this is
often successful.
Early Symptom Manifestations
Due to reduced physiological reserve, older
patients often develop symptoms at an
earlier stage of the disease, e.g. urinary
retention by mild prostatic enlargement,
heart failure by only mild hyperthyroidism,
nonketotic hyperosmolar coma by only mild
glucose intolerance. Thus, treatment of the
underlying disease can be easier in the elderly
because it may be less advanced at the time of
presentation. It is important that any symptom,
particularly those associated with functional
Table 26.2  Hidden illnesses in elderly
• Dementia
• Depression
• Falling
• Hearing loss
• Incontinence
• Musculoskeletal stiffness
• Orodental problems, poor nutrition
• Sexual dysfunction
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status, such as headache, fatigue, insomnia,
irritability, abdominal pain, indigestion, low
back pain, or simply not feeling well should
be taken seriously and evaluated promptly, so
that management can be planned early.
Multiple Causes
Since many homeostatic mechanisms (i.e.
milieu interieur) may be compromised
concurrently, one problem may have several
causes. Treating each alone may do little
good; treating all may be of many benefit.
For example, urinary incontinence may
be worsened by fecal impaction, drugs,
and excess urinary output; treating these
contributory factors simultaneously will result
in substantial functional improvement, even if
the disease per se is untreatable.
Multiple Pathology
Several disease processes may coincide; their
combination usually leading to the development
of new disability. For example, combination
of senile cataract and arthritis leading to falls;
dyspnea may be contributed by a pulmonary as
well as a cardiac pathology; hence, all possible
causes should be looked into. As patient may
have multiple complaints due to multiple
diseases or factors, trying to explain all findings
by a single diagnosis, as is customary in adults
(i.e. unitary model of diagnosis) is usually
inappropriate in the old. Once people are in
their 60s or 70s, they commonly show evidence
of several different pathological possesses, some
active, others inactive. As a consequence of
multiple diseases, the symptoms and signs of a
new disease may be wrongly attributed to the old
disease already diagnosed. A problem-oriented
approach in relation to functional assessment
that includes the ability to perform “activities
of daily living” (e.g. dressing, cooking, eating,
drinking, washing, bathing, getting in and out of
bed, continence and shopping) is very helpful to
assess the overall morbidity caused by disease
process.
 Chapter 26: Aging and Geriatric Concepts 247
Delayed or No Reporting of Diseases/
Dysfunctions (Table 26.3)
Though diseases manifest earlier in elderly
due to poor physiological reserve, elderly
report late or ignore symptoms (Table 26.3).
This may be due to low expectation of health,
misinterpretation of symptoms as normal
markers of aging, fear of hospitalization, social
stigma, economic factors, or dementia. Poor
communication skills and unawareness of
physician about geriatric illnesses may also
contribute to delayed presentation.12
Mild Disease may Result in Serious
Dysfunction
In the elderly, homeostatic mechanisms to repair
any damage are impaired by pre-existing diseases
or by physiological decline (i.e. homeostenosis),
hence even mild diseases may tip the balance,
e.g. urinary retention may be precipitated by
mild prostatic hypertrophy, congestive cardiac
failure by mild hyperthyroidism.
Certain Patterns of Disease
Presentation in Elderly
Certain patterns of presentation of diseases
are peculiar to old people, such as Immobility,
Instability (falls), Incontinence, and
Intellectual impairment. These “four Is” have
been designated as “giants of geriatrics” (as
described by Bernard Isaacs 1924–1995).
These are extremely common and present
challenges to diagnostic skills in determination
of precipitating cause and to uncover
exacerbating factors. Apart from these four
Table 26.3  Factors contributing to delayed
presentation of illness
• Insidious and vague symptoms associated with
illness
• Ageism—Patients and families assume symptoms
as a part of normal aging
• General tendency to avoid burdensome tests; fear
of economic or social consequences
• Communication deficits due to speech problems,
forgetfulness, poor vision and hearing deficit
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classical giants of geriatric, Table 26.4 includes
the “modern” geriatric giants in elderly people.
Normal Occurrence of Nonspecific
Abnormalities (Table 26.5)
Many findings that are abnormal in younger
patients are relatively common in older people,
e.g. impaired glucose tolerance, premature
ventricular contractions, low bone mineral
density, bacteriuria. They are usually incidental
findings and benign in nature. On the other
hand, a number of illnesses in the elderly have an
atypical presentation (Table 26.6). However, the
belief about silent presentation of diseases is not
true. This appearance is due to clinical features
being masked, ignored or becoming atypical due
to the interaction of different diseases or drugs
being administered.
Dual Role of Therapy and Prevention
Both therapeutic and preventive measures
are effective in the management of diseases
Table 26.4  The I’s of geriatrics—classical and modern
geriatric giants
• Instability (frailty)
• Incontinence
• Intellectual impairment
• Incoherence (delirium)
• Insulin resistance (diabetes mellitus)
• Immobility
• Inanition (malnutrition)
• Impoverishment
Table 26.5  Commonly present nonspecific
abnormalities in elderly
• Diminished skin turgor
• Senile purpura and hirsutism
• Wasting of muscles of hand
• Ventricular premature beats
• Systolic murmurs—mostly benign aortic stenosis
• Rales at bases of lungs due to fibrotic changes
in lung
• Osteoporosis leading to vertebral compression
fracture
• Impaired GTT
• Testicular atrophy
• Diminished vibratory sensation in toes
• Diminished or absent ankle jerks
• Mild renal insufficiencies
 248  Section 6: Geriatric Health
Table 26.6  Atypical presentations of specific illnesses
in elderly
• Infectious disease without fever, leukocytosis,
tachycardia
• Depressions without sadness
• Myocardial infarction without chest pain
• Apathetic thyrotoxicosis
• Silent malignancy (mass without symptom)
• Nondyspneic pulmonary edema
• Silent surgical abdomen
in elderly people. For example, fractures may
be prevented by improving bone metabolism,
improving balance, and strengthening legs
by exercises and physiotherapy. Treatment
of hypertension and transient ischemic
attack prevents falls and neurological deficits.
Annual immunization against influenza
is modestly found to be cost-effective in
preventing complications due to influenza and
pneumonia in the elderly.13
Conclusion
As family physicians, we need to first recognize
that our patient profile is aging, and we
need to be better informed about caring for
the elderly. In the elderly and frail patients,
multiple diseases, physiological decline in
multiple organs, co-administered drugs,
and psychological factors may interact to
mask clinical features or make them atypical.
Besides, delayed reporting by patients, poor
communication skills, and unawareness
about geriatric problems and their atypical
presentations of illness in physicians add to
the problem of diagnosis.
Since the majority of the elderly live
within the community, family physicians
are in the best position to provide their care.
An understanding of the above concepts in
the development of the disease in elderly
patients facilitate family physicians to the
common themes in the approach to the
assessment of the elderly patients, the choice
of preventive measures, and the management
of multifactorial geriatric syndromes.
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References
1. Partridge L, et al. Messages from mortality: the
evolution of death rates in the old.Trends Ecol
Evol, 1999;14(11):438–442. [PMID: 10511720:
Abstract].
2. Neil M. et al. Geriatric Medicine. In: Harrison’s
Internal Medicine, vol. 1, 16th edn. p.44.
3. Colledge NR. Frail older people. In: Davidson’s
Principles and Practice of medicine, 19th edn.
Churchill Livingstone. p.238.
4. www.jlgh.org/JLGH/media/Journal.../JLGH_
V3n3_p105-107.pdf
5. http://www.bgs.org.uk/About/composition.htm
6. American Association of Retired Persons
(AARP) Statement to the 42nd Session of
the UN Commission on Population and
Development. Publish Date: April 1, 2009.
URL:http://www.un.org/esa/population/cpd/
cpd2009/comm2009.htm ;
http://www.aarpinternational.org/resources/
re s o u rc e s _ s h o w . h t m ? d o c _ i d = 8 5 4 2 1 0 .
(Accessed on 23-01-2012)
7. Aggrawal A. et al. 1999: the International
Year of the Older persons. J Ind Med Assoc,
1999;97(4):117–8.
8. Uton M. Rafei, WHO Regional Director for
South-east Asia: Message on the Occasion of
World Health Day, 7th April 1999. J Ind Med
Assoc, 1999;97(4):159.
9. Ramli AS et al. Managing chronic diseases in
the Malaysian primary health care – a need
for change. Malaysian Family Physician, 2008;
3(1):7–13.
10. Fortin M et al. Prevalence of multimorbidity
among adults seen in family practice. Ann Fam
Med, 2005;3(3):223–8.
11. Uijen AA, et al. Multimorbidity in primary care:
prevalence and trend over the last 20 years. Eur
J Gen Pract, 2008;14(Suppl 1):28–32.
12. Helen M. Fernandez et al. House Staff Member
Awareness of Older Inpatients’ Risks for
Hazards of Hospitalization. Arch Intern Med,
2008;168(4):390–6.
13. Vaccines for preventing influenza in the elderly.
Web site: http://www.cochrane.org/reviews/
en/ab004876.html
 27 Comprehensive
Geriatric Assessment

“It is not enough for a great nation to have added new years to life. Our objective must be to add new life
to those years.”
– John F. Kennedy

Introduction Table 27.1  Components of comprehensive geriatric

assessment
Comprehensive ger iatr ic ass essment
Component Elements
(CGA) is defined as a multidimensional
Medical assessment Problem list
medical, functional, psychosocial, social and Comorbid conditions and
environmental evaluation of an older* person’s disease severity
problems and resources (Table 27.1)1, in order Medication review
Nutritional status
to develop a coordinated and integrated plan
for treatment and long-term follow-up. 2,3 Assessment of Basic activities of daily
functioning living
The CGA means any look at an older patient, Instrumental activities of
which measures the person’s performance daily living
of the survival skills required to negotiate Activity/exercise status
Gait and balance
everyday life using standardized protocols. The
individual is assessed in relation to his or her Psychological Mental status (cognitive)
assessment testing
environment and a comprehensive functional Mood/depression testing
data is obtained, which includes essential Social assessment Informal support needs
physical and cognitive functioning, physical and assets
environment of the patient, socio-economic Care resource eligibility/
financial assessment
situation of the patient, and patient’s wishes
concerning quality of life (Fig. 27.1).4 Environmental Home safety
assessment Transportation and
The CGA is time and labor intensive. telehealth
Ideally, under these circumstances, an
interdisciplinary team—consisting of medical,
psychological and nutritional consultants, intervention strategy, initiate treatment, and
physical and occupational therapist and other follow-up on the patient’s progress.
specific healthcare professionals such as Although the research has shown that
geriatricians—performs a detailed assessment, comprehensive assessment techniques have
analyze the information, formulate an several clinical benefits for geriatric patients and

*The age of 60 or 65 years roughly equivalent to retirement ages in most developed countries is said to be
the beginning of old age.

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 250  Section 6: Geriatric Health
Fig. 27.1  Components of comprehensive geriatric
functional assessment
that many physicians use some techniques of
geriatric assessment, most practicing physicians
do not perform comprehensive assessment
of geriatric patients.5 Most of the healthcare
benefits are seen in hospital or ward-based
management units with little contribution from
ambulatory or team-based care.6
However, in clinical practice, CGA can be
improved by selectively targeting community-
dwelling elderly people, (i.e. those above
60 years age), using a standardized self-
administered questionnaire (Table 27.2) for each
of four “geriatric syndromes”, namely depression,
urinary incontinence, falls and functional
impairment (i.e. basic activities of daily living),
and thus can identify elderly people likely to
benefit from geriatric assessment. Based on these
findings probable etiologies regarding impaired
anatomy and physiology can be identified and
practical solutions planned to enhance their
quality of life.7,8
Barriers to CGA
Although, family physicians have provided
the bulk of health care to the elderly and
probably will continue to do so, they are
neither trained nor expected to perform such
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Table 27.2  Self-administered questionnaire
Condition Screening questions
A – Depression Have you felt sad or depressed
during the past 4 weeks?
B – Falls Have you fallen all the way to the
ground or fallen and hit something
like a chair or stair during the past
12 months?
C – Urinary Do you have trouble holding urine;
incontinence did you lose urine when you don’t
want to; does urine come out by
itself when coughing or laughing
in the past 12 months?
D – Functional 1. During the past 4 weeks: did
impairment you have any difficulty while
eating, dressing, and bathing
and while moving in and out of
bed or chair?
2. During the past 4 weeks: did you
have physical difficulty walking
in and around your home or
walking some distance outside
or shopping?
3. During the past 4 weeks: did
you have any physical difficulty
driving a car or using other
transportation?
4. During the past 4 weeks: did
you have any physical difficulty
participating in community
activities or volunteer work or
visiting friends and relatives?
an evaluation alone or at any one time. 9,10
Studies have identified certain barriers to
improving geriatric education in family
practice residencies which include:11–13
™™ Variable and/or inadequate training and
education in geriatric medicine;
™™ Lack of knowledge, professional education,
experience, and/or interest among phy­
sicians in dealing with the complex needs
of the elderly;
™™ Lack of staff supports, such as geriatric
nurse specialists, whose role is to ensure
optimal geriatric care as defined above;
™™ Disinterest among new-to-practice
physicians in treating elderly patients
who present with more challenging and
time-consuming problems; and
 Chapter 27: Comprehensive Geriatric Assessment 251
™™ Fee-for-service payment systems leading to
financial disincentive to caring for elderly
patients who tend to require more time for
comprehensive assessments,
However, family physicians are expected to
be familiar with critical areas of everyday life
of older patients, understand and synthesize
their needs, from suitable medical decision,
and involve specific key personnel who can
assist in this task.14,15
Medical Assessment
Like any effective medical evaluation, the
geriatric assessment needs to be sufficiently
flexible in scope and adaptable in content to
serve a wide range of patients.
Much of what applies to the examination
of the younger patient applies equally to an
elderly one, but a geriatric assessment has
particular assessment, which is uniquely
“geriatric” in three general ways:
1. It focuses on elderly individuals with
complex problems.
2. It emphasizes functional status and quality
of life.
Table 27.3 Disciplines involved in the care of the
elderly
Core team
• Geriatric medicine and psychiatry
• Nursing
• Physiotherapy
• Occupational therapy
• Social work
Other disciplines
• Speech therapy
• Hearing services
• Continence advice
• Ophthalmology and opticians
• Clinical psychology
• Chiropody
• Cosmetic services
• Dentistry
• Recreational services
• Volunteer services
• Community liaison nursing
*Ref. Appendix 6
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3. It frequently takes advantage of an inter­
disciplinary team of providers (Table 27.3).
The important aspects which need to be
aware of are:
™™ Whether the patient looks acutely ill,
chronically ill, or generally well
™™ Non-specific or atypical presentation of
disease
™™ Presence of multiple diseases
™™ Prevent complications to the extent
possible
™™ To always seek the reversible causes of
disability.
The principles of medical assessment include:
™™ History
™™ Physical examination
™™ Investigations
™™ Mental status examination
™™ Functional assessment
™™ Advance directive.
History Taking and its Pitfalls
Aging patients pose special opportunity and
special problems. They become increasingly
aware of their personnel aging and begin to
measure their lives in terms of the years left
rather than the years lived. It is normal for the
older people to reminisce about the past and
to reflect upon previous experience, including
joys, regrets, and conflicts. Listening to this
process of review gives important insights into
their lives, helping to plan their priorities and
goals, besides their healthcare aspects.
Aging patients have longer histories and
they may narrate them more slowly; often
requiring extra time. Therefore, do not try to
accomplish everything in one visit.
If the patient is unable to comprehend or
communicate, information should be sought
from family, friends or caregivers (Table 27.4).
The use of questioners*, which can
be completed at leisure at home with the
 252  Section 6: Geriatric Health
Table 27.4 Tips for communicating effectively with
elderly
• Provide a well-lit, moderately warm setting with
minimal background noise and safe chairs and
access to the examining table
• Face the patient and speak in low tones; make
sure the patient is using glasses, hearing devices,
and dentures if needed
• Adjust the pace and content of the interview to the
stamina of the patient; consider two visits for initial
evaluations when indicated
• Allow time for open-ended questions and
reminiscing; include family and caretakers when
needed, especially if the patient has cognitive
impairment
• Make use of brief screening instruments, the
medical record, and reports from allied disciplines
• Carefully assess symptoms, especially fatigue,
loss of appetite, dizziness, and pain, for clues to
underlying disorders
• Make sure written instructions are in large print
and easy to read
Sources: 1. Bates’ guide to physical examination and history
taking. Ch.20, The older adult.
2. C o m m u n i c a t i n g w i t h o l d e r p e o p l e . W e b
site: http://www.who.int/ageing/publications/
PPCommunicationwithOlderPeople.pdf
help of family members, is most useful as
complimentary to the medical interviews.
Important Specific Areas
Important specific areas to focus on are:
™™ Present complaints and past medical history,
including hospitalization: Patients may
respond to their questions slowly, often
pausing, but this does not necessarily indicate
mental impairment. In some cases, slowness
of verbal response may be due to Parkinson’s
disease, myxoedema or depression.
™™ Personal history: About diet, sleep, tobacco,
alcohol, substance abuse, exercise and
leisure activities. An inquiry into the
activities of daily living, like bathing,
dressing, toileting, continence must be
skillfully incorporated and evaluated.
™™ Family and household issues: For example,
number of people, friends, relationship,
attitude, comforts; important experiences
like upbringing, marriage, retirement, and
finance.
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Table 27.5  Signs and symptoms of depression
• Tiredness and loss of energy
• Sadness that doesn’t go away 
• Loss of self-confidence and self-esteem
• Not being able to enjoy things that are usually
pleasurable or interesting
• Feeling anxious all the time
• Avoiding other people, sometimes even your
close friends
• Feelings of helplessness and hopelessness
• Sleeping problems—difficulties in getting-off to
sleep or waking up much earlier than usual
• Very strong feelings of guilt or worthlessness
• Thinking about suicide and death
• Self-harm
™™ Psychological: Especially for any evidence
of depression (Table 27.5).
™™ Mental and emotional evaluation: Early
in the interview try to form some idea of
whether the patient is confused or not. This
can be done by introducing questions from
Abbreviated Mental Test (Table 27.6), after
you have gained confidence of the patient
by stating a comment such as, “ I am now
going to ask you some questions which
may seem very simple to you, but they are
an important part of my examining you; I
hope you don’t mind.”
™™ Current health status: It includes a history
of allergies, immunizations, screening
tests, and use of safety measures (Table
27.7).16
™™ Medications, including OTC drugs :
Medications are so often likely to be part of
the problem, rather than part of the solution,
and hence become a high priority focus,
along with compliance. With the multiplicity
of disease in the elderly, medications to
multiply, leading to more likelihood of side
effects and iatrogenic disease. Keeping an
elder’s drug profile in a state that optimizes
the function is an enterprise, which demands
a lot of surveillances, repeated assessment,
and frank judicious risk assessment on the
part of the attending physician. Therefore,
the physician should regularly assess what
drugs the patient is taking, their timing
 Chapter 27: Comprehensive Geriatric Assessment 253
Table 27.6  Abbreviated mental test
• Age—must be correct
• Time—without looking at a timepiece, correct to
the nearest hour
• Address—e.g. 7, Race course road, New Delhi.
Given as a test of immediate memory, and retested
at the end
• Month—must be correct
• Year—must be correct
• Name of place, e.g. hospital, clinic, home
• Date of birth—exact
• Date of specific events, e.g. wedding, retirement,
independence day
• Name of the present leader/monarch, e.g. who is
the President or Prime Minister of our country?
• Counting backwards from 20 to 0; can prompt to
18 and patient may self-correct or hesitate
Recall the address given as a test above.
A score of 6 or less out of 10 strongly suggest
mental impairment
Table 27.7  Home safety for the elderly
Fall Prevention
• Keep clutter away from the floor space
• Ensure that all floor surfaces are non-slip, securely
in place and in good condition
• Arrange furniture to aid easy movement
• Keep the stairs clear at all times and make sure
that the handrail is secure
• If at all you have to climb up always use proper
steps
• Fit safety rails by the toilet and the bath to assist
entry and exit
• Use non-slip rubber mats in the bath or shower
• Discard poorly fitting slippers or shoes; don’t wear
high heels
• Avoid trailing clothes which may trip you up
Burns and scalds prevention
• Ensure that all electrical appliance leads are not
left trailing on the floor. Where necessary these
could be stapled along the walls
• Use long life light bulbs as they don’t require
frequent changing
• Boil only enough water for your immediate needs
• Always run cold water first when having a bath
or a shower
• Consider fitting thermostatically controlled bath
taps
• Buy a cordless kettle or one with a coiled flex
• Consider fitting smoke alarms
For more details about “Home Safety Checklist for
Older Consumers”, please visit - http://www.nachi.org/
elderlysafety.htmfor
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and frequency, besides cautioning them of
important side effects.
™™ Vision, hearing and mobility: If eye sight
or hearing is a problem, difficulty in
communicating and taking instructions
naturally follow, so that problems related
to special senses often need specific or
direct questioning; e.g. eye pain, diplopic,
scotoma, difficulty driving, reading and
watching television, sudden vision loss.
High-toned deafness, i.e. presbycusis—
gradually progressive hearing loss with particular
difficulty understanding words and conversation,
especially when there is high level of ambient
background noise—commonly occurs in the
elderly; therefore, the physician has to speak in
a clear low-pitched voice (Tables 27.4 and 27.8).
Failure to appreciate deafness may lead to an
incorrect diagnosis of dementia. If the patient has
a hearing aid, make sure he/she uses it during the
interview.
Table 27.8  Suggestions for communicating with the
hearing impaired
• Face the elderly directly; position yourself within
a meter of the patient, they must be able to see
you to hear you
• Maintain a good light on your face. Face a window
or a lamp so the light illuminates your mouth as
you speak. Elderly with hearing loss rely a great
deal on lip-reading
• Ensure that you have the patient’s attention.
Establish eye contact and address what you want
to talk about clearly and concisely
• Eliminate background noise. When you are
beginning a conversation turn the radio or TV
down or off
• Speak slightly louder than normal, but do not
shout. Speak slowly, pausing between phrases
and sentences. Articulate carefully without
exaggeration
• Rephrase rather than repeat verbatim. If you
cannot get your words across rephrase what you
are saying and change up the sentence structure
• Check comprehension periodically. Elderly often
nod in agreement to indicate they understand
what you are saying to avoid frustration and
embarrassment, regardless of whether or not they
truly absorbed what you said. If you are unsure
if the elderly understood you, have them repeat
your words back to you
 254  Section 6: Geriatric Health
Bereavement: Mourning and grief reactions
occur normally after the death of a loved one.
In elderly people, this emotional trauma leads
to increased incidence of physical and mental
illness, and generally present with somatic
symptoms following loss, including increased
risk for abuse of alcohol, tobacco, and
medications. Besides chronic illness, physical
impairment, unrelieved pain, financial stress,
and social isolation are known risk factors
leading the elderly to contemplate or commit
suicide.
Most of the elderly who commit suicide do
so not long after visiting a physician. A review of
studies analyzing this clinical scenario estimated
45% of those dying by suicide saw their primary
care physician in the month before their death.17
Only 20% saw a mental health professional
in the preceding month. Women and older
patients are more likely to have sought care in
the month before suicide than men and younger
patients. Thus, the responsibility for prevention
lies not only with the family and friends of the
suicidal elderly person but with the physician
as well. These aspects, as also suicide warning
symptoms and signs (Table 27.9) need to be
assessed carefully while interviewing the elderly.
The family physician, who has the intimate
knowledge of patients’ medical, functional, and
social problems, is in a unique position to help
the bereaved to express their feelings and come
to terms with their loss.
Physical Examination and its Pitfalls
The conventional physical examination
consisting of system review, past and family
history and medications is similar to that of the
adult, but certain areas require more attention,
depending in part on clues from the history,
e.g. cognition and activities of daily life. The
examination, besides requiring great attention
*Ref. Web site - http://www.mna-elderly.com/forms/mna_guide_english.pdf , for “A guide to completing
the Mini Nutritional Assessment (MNA®)”.
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Table 27.9  Suicide warning signs
• Appearing depressed or sad most of the time.
Feeling hopeless and/or worthless, Feeling
excessive guilt or shame. (Untreated depression
is the number one cause for suicide)
• Losing interest in things or activities that are
usually found enjoyable
• Withdrawing from family and friends. Cutting back
social interaction, self-care, and grooming
• Exhibiting a change in personality. Experiencing
dramatic mood changes. Feeling strong anger or
rage. Acting recklessly
• Breaking medical regimens (such as going off
diets, prescriptions)
• Experiencing or expecting a significant personal
loss (spouse or other)
• Putting affairs in order. Giving away prized
possessions. Writing a will or making changes
in wills
• Stock-piling medication or obtaining other lethal
means
• Preoccupation with death or a lack of concern
about personal safety. Remarks such as "This is
the last time that you'll see me" or "I won't need
any more appointments" should raise concern
• The most significant indicator is an expression of
suicidal intent
to details, is necessarily time-consuming.
But the time involved is never wasted. The
information collected at this stage plays a
vital role in planning patient’s ongoing care.
Additionally, physicians’ interest in the well
being of their patients helps consolidate the
doctor-patient relationship.
The following areas should be examined.
™™ Weight, height: Evaluate BMI and nutritional
status.* In the elderly it is often better to
have a BMI between 25 and 27, rather than
under 25. In the elderly, a slightly higher
BMI may help protect from osteoporosis.
On the other hand, being too thin and
having a BMI that’s below the healthy range
(18.5 to 24.9) can also be a health concern.
Although BMI alone cannot predict health
risk, most experts say that a BMI greater than
30 (obesity) is unhealthy.
 Chapter 27: Comprehensive Geriatric Assessment 255

™™ Temperature: The normal oral body
temperature is close to 37°C (98.6°F). Fever
is defined as an oral temperature greater
than 38°C (100°F).
Recording by regular oral thermometer may
be less accurate. Rectal temperature recorded
with low reading calibrated thermometer is
preferred. If they are not available, a regular
oral thermometer should be set aside and used
solely for rectal temperature recording.* Often,
elderly patients develop systemic infections
with the body temperature remaining in
the normal range. Fever, the cardinal sign
of infection, may be absent or blunted 20–
30% of the time. In the old, bacteremia,
endocarditis, pneumonia, and meningitis may
present with lower fever than in the young.
Similarly, acute surgical abdomens, e.g. acute
cholecystitis, perforation, and appendicitis
often present with temperatures <37.5°C
(<99.5°F). An absent or blunted fever response
may, therefore, contribute to diagnostic delays
in this population, which is already at risk
for increased morbidity and mortality due to
infection.18
™™ Blood Pressure: The merits of treating
hypertension in elderly have now been
well documented. More Important
in the elderly is postural (orthostatic)
hypotension, which is a reduction of
“systolic” blood pressure of at least 20
mm Hg or a reduction of” diastolic” blood
pressure of at least 10 mm Hg within 3
minutes of erect standing.
There are many causes of postural
hypotension (e.g. diabetes, autonomic
neuropathies, myocardial infarction,
aortic stenosis, vasodilatation as a result
of fevers). The characteristic clinical
features are complaints of dizziness and
faintness, and even when these symptoms
are not present postural unsteadiness and
falls may be present. In the early stages
of the condition, the drop in the blood
pressure may only be present first thing in
the morning, when the circulating blood
volume is at its lowest. In order to be
certain that postural hypotension is not
present, the pressure should be measured
when the patient first rises in the morning.
™™ Hearing, vision and speech: The elderly
often become isolated because of problems
with these functions. Visual impairment is
an independent risk factor for falls. Testing
vision by using ophthalmic ‘pin-hole’ and
a Snellen chart may be needed as initial
screening method, followed by referral to
optometric services.
During the history, the physician,
can ask specific questions** which help a
simple assessment of hearing acuity, e.g.
does a hearing problem cause you to feel
embarrassed when meeting new people?;
does a hearing problem cause you to feel
frustrated when talking to members of your
family?; does a hearing problem cause you
difficulty when visiting friends, relatives, or
neighbors?.
Hearing acuity can be tested by simple
methods such as asking the patient to
identify the sound of a ticking watch
or the presence of two fingers rubbing
together by the ear. Difficulties with speech
comprehension can be assessed by the
“whisper test” (Table 27.10). An inability to
repeat 50% of the words can identify those
patients who may have poor results with
the hearing-aid because of dysfunctional
auditory processing. Tuning forks are of
limited utility in assessing auditory acuity.

*In clinical practice the rectal site has been viewed as an effective minimally invasive method to estimate the
“true” body temperature. Traditionally the oral and axillary readings are adjusted to the rectal temperature
by adding 0.3°C and 0.5°C, respectively (Betta et al, 1997).
**Ref. web site - http://consultgerirn.org/uploads/File/trythis/try_this_12.pdf

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 256  Section 6: Geriatric Health
Table 27.10  Conducting the whispered voice test
• T
 he examiner stands arm’s length (0.6 m) behind
the seated patient and whispers a combination of
numbers and letters (e.g. 4-K-2) and then asks
the patient to repeat the sequence
• T
 he examiner should quietly exhale before
whispering to ensure as quiet a voice as possible
• If the patient responds correctly, hearing is
considered normal; if the patient responds
incorrectly, the test is repeated using a different
number/letter combination
• T
 he patient is considered to have passed the
screening test if they repeat at least three out of
a possible six numbers or letters correctly
• T
 he examiner always stands behind the patient to
prevent lip-reading
• E
 ach ear is tested individually, starting with the
ear with better hearing, and during testing the
non-test ear is masked by gently occluding the
auditory canal with a finger and rubbing the tragus
in a circular motion
• T
 he other ear is assessed similarly with a different
combination of numbers and letters.
Source: Sandi Pirozzo et al. Whispered voice test for screening
for hearing impairment in adults and children: systematic review.
BMJ. 2003 October 25; 327(7421): 967. [PMCID: PMC259166]
Check the patient’s ears for wax.
Otoscopic examination for cerumen
or serous otitis is essential and should
be done before any testing for hearing
loss. Cerumen obstruction commonly
contributes to hearing loss, and its removal
can dramatically improve acuity.
Hearing aids are often not worn even
when provided. Many old persons and
their relatives are reluctant to confront
the reality of hearing handicap and try
to hide the fact that they need sound
amplification. Major barriers to improved
hearing in older adults include lack of
recognition of hearing loss; perception
that hearing loss is a normal part of aging
or is not amenable to treatment ; and
patient nonadherence with hearing aids
because of stigma, cost, inconvenience,
disappointing initial results, or other
factors. Besides, to the physician, hearing
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loss is invisible: it cannot be seen, heard,
or touched. It may not be noticeable in
a quiet office environment and in one-
to-one conversation. Therefore, it is
imperative that primary care physicians
screen patients—especially those age 65
and older—for hearing loss, and refer
them to an audiologist if hearing loss is
suspected. 19 It’s therefore crucial that
family physicians guide their patients to
accept hearing loss and to support the
more open use of amplification systems.
Today’s hearing aids differ significantly
from their analog predecessors. Changes
in technology, assistive devices, and the
development of the cochlear implant
have improved the ability of the hearing
impaired to compensate for their disability.
However, the benefits of new technology
should not overshadow the importance of
simpler considerations such as how we can
speak more effectively to those who have
difficulty in hearing.
When the patient has a hearing aid,
physicians should make sure the battery
is working and that the patient knows how
to use the aids. Also, physicians should
get acquainted with the mechanism and
functioning of hearing aid.
Even in the absence of speech disorders
related to the neurological diseases such as
stroke, Bell’s palsy or Parkinson’s disease,
speech in the elderly may be unclear as a
result of aging processes affecting the speech
mechanism such as diseases of oral cavity,
tongue, pharynx and larynx; dental trouble—
chronic irritation may lead to oral ulcers;
ill-fitting dentures—poor-fitting dentures
may be associated with oral ulceration and
poor nutrition. The “portcullis” sign (i.e.
the top denture falling on to the bottom one
when the mouth is opened) may be due to
poor fitting, but its de novo presence may
indicate dehydration, or a stroke leading to
loss of tone in the buccal musculature. The
 Chapter 27: Comprehensive Geriatric Assessment 257
“caviar tongue” (i.e. clusters of sublingual
varicosities) seen sometimes in elderly is a
benign condition.
™™ Skin: With aging the skin looses its elasticity.
There is decreased subcutaneous fat and
loss of collagen. The skin sags and wrinkles
appear. There is increased capillary fragility—
the blood vessels are easily disrupted,
resulting in bruises. These changes lead to
senile purpura and their presence do not
indicate bleeding disorders. Benign senile
angiomas, i.e. cherry hemangiomas (De
Morgan Spots) are commonly found on the
trunk and sometimes also occur on the face,
neck, scalp, arms and legs.
The incidence of malignant basal
cell and squamous carcinomas is more;
hence their clinical diagnosis should
be confirmed by performing a biopsy of
the suspected lesion for histopathologic
interpretation.
Particular attention should be paid to
the “pressure areas” as the development of
pressure sore is a disaster to the patient. Risk
factors include immobility, fecal or urinary
incontinence, diabetes, glucocorticoid use,
and poor nutrition. Prevention is essential,
e.g. positional rotation every few hours to
distribute the compressive forces and to
minimize further injury.
™™ Thyroid: Despite the increased frequency
of thyroid problems in older individuals,
physicians need a high index of suspicion to
make the diagnosis since thyroid disorders
often manifest as a disorder of another
system in the body. While some of the
symptoms of thyroid disease are similar
to those in younger patients, it is not
uncommon for both hyperthyroidism and
hypothyroidism to be manifested in subtle
ways in older patients, often mimicking
symptoms of aging or masquerading
as diseases of the cardiovascular,
gastrointestinal, or nervous system (Tables
27.11 and 27.12). Typical symptoms may be
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Table 27.11 Hyperthyroidism—clinical presentation
in the elderly
• Nonspecific symptoms
– Anorexia
–  Weight loss and loss of appetite
• Constipation
– Cardiovascular:
–  Atrial fibrillation
– Dyspnea
– Angina
–  CHF and MI
• Apathetic thyrotoxicosis”
• Muscle weakness and proximal muscle wasting
Table 27.12 Hypothyroidism—clinical presentation
in the elderly
• Cardiovascular
– Bradycardia
–  Low voltage QRS
–  Diastolic hypertension
–  Increased LDL
–  Pericardial effusion
• Neuropsychiatric N
–  Lethargy, fatigue, sleep disturbance
–  Poor concentration, cognitive impairment
– Depression
– Myxedema madness (confusion, paranoia) in
severe disease
• Pulmonary
–  Sleep apnea
–  Exquisite sensitivity to sedative medications
absent and may be erroneously attributed to
normal aging or coexisting disease. Physical
examination of the thyroid gland may not be
helpful, as the gland is often shrunken and
difficult to palpate. If there is a suspicion
of malignant disease, early biopsy or fine
needle aspiration for cytology should be
considered.
™™ Breasts : The breasts should not be
overlooked, since older woman are more
likely to have breast cancer and less likely
to do breast self-examination.
Some observant women will volunteer
that they have noted a recent change in the
size of the breast, irregularity in the shape of
the breast or asymmetry. However, the area of
concern to the patient should be examined in
detail. The site and physical characteristics of
 258  Section 6: Geriatric Health
any masses including size, tenderness, shape,
consistency, mobility, margin and fixation
to skin or muscle, including nipple shape,
retraction, discharge, and supraclavicular and
lower cervical lymph nodes should be noted.
™™ Falls and Gait Impairment: Falls are the
leading causes of non-fatal injuries in
older persons, and their complications
are the leading cause of death from injury
in elderly. Many elders harbor fear of
hospitalization, due to which they may
suppress history of fall. Because elderly
persons may not volunteer the information,
physicians should, on at least a yearly basis,
ask their elderly patients about any falls
and ask about and look for any difficulties
with balance or gait.20*
The most serious consequences of the
geriatric fall syndrome are fractures of hip,
humerus, wrist and pelvis. Fear of falling
and self-limitation of physical activity is
self-imposed psychological impairments.
There is a pathological cascade from age-
associated gait and balance disorders
to locomotor falls and further to fall-
related fractures. Significantly increased
fall risk caused by gait and balance
disorders can be considered as a distinct
chronic pathological condition. It is
strongly age-related and definitely has
a multifactorial origin. The term “age-
associated multifactorial gait disorder” has
been coined for this condition.21
While assessing gait and balance,
physician should pay attention to the following
“Get up and go” Test (Table 27.13). This test
is done in ambulatory patients only. One
practice run is allowed, i.e. have the patient
*A detail “patient visit note–falls and motility disorders” is available at web site - http://www.ncbi.nlm.nih.
gov/pmc/articles/PMC2686332/figure/f1-cia-2-545/
**This test is often timed, e.g. Expanded Timed Up-and-Go’ (ETUG) test, and different cut off times—varying
from 10 to 30 seconds—exist for different indications. In the present setting, where the physician is trying
to identify the major or multiple causes of the fall, the end result is to be able to tailor the treatment plan
by identifying abnormalities in gait or stature, so timing is not as critical.
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Table 27.13  Get up and go test
• The patient should sit comfortably in a straight-
backed, high-seat chair with arms rests
• Ask the patient to rise from the chair (with or
without an assistive device, as is his/her usual
manner of ambulation)
• Ask the patient to stand still momentarily (10
sec) with eyes open (with or without an assistive
device, as is his/her usual manner)
• Ask the patient to stand still momentarily (10
sec) with eyes closed (again with or without an
assistive device), you may need to guard them
from falling
• Ask the patient to walk approximately 50 ft forward
(with or without a device and/or assistance as
appropriate, preferably toward a wall)
• Ask the patient to turn around at the end of 50 ft.
• Ask the patient to walk back to the chair, another
50 ft, to the original destination
• Ask the patient to sit down when he/she reaches
the chair
walk through the test once before to become
familiar with the test. The physician makes
“qualitative” observations about each aspect
of the mobility trial.**
The physician carefully notes—Is the
patient able to rise from a chair without use
of arms in a single smooth attempt? Is there
stability immediately upon standing, or does
the patient stagger? Is balance maintained
when the patient is pushed lightly on the
sternum? Is there steadiness when standing
with eyes closed? Can a 360-degree rotation
be achieved in a smooth, continuous motion?
How is walking initiated? Are the steps equal?
Is there a wide based gait? Is a walking aid
(cane, walker) necessary? 22
Incontinence: Many patients fail to tell and
discuss symptoms relating to urinary and fecal
incontinence. Physicians must evaluate these
symptoms because suitable interventions
 Chapter 27: Comprehensive Geriatric Assessment 259

can improve most patients. In men, rectal
examination, scrotum, and testes; and in
woman vaginal examination and cervical
smear, if appropriate, may be indicated.
Aids and appliances: This is an essential part
of the examination. Physicians must verify
the aids, such as walking stick, wheel chairs,
inclusive of their tyres and breaks, walkers,
armchairs, dining chairs, toilet aids for their
suitability and safety.
artery disease) may be preferred to invasive
coronary angiography in the evaluation of
elderly with suspected CAD in the elderly.
™™ The views of the patient and, where
appropriate, the family: The views of the
patient and family/relatives should also
be taken into account. However, relatives
should never be made to feel responsible
for difficult decisions, e.g. consenting for
HIV screening tests, or biopsy procedures.

Mental Status Examination

Investigations23,24
Mental state examination would revolve
In the elderly, frequently only a clinical
around evaluation of cognition (i.e. higher
assessment is required. Some simple laboratory
mental functions) and depression.
investigations that may be helpful are—complete
The abbreviated mental test (Table 27.6)
blood count, renal function panel, chest X-ray,
consisting of ten point assessment score referred
electrocardiogram and lipid profile. In a frail
to earlier have their limitations to detect mild to
patient, thyroid function test, vitamin B12, folate,
moderate intellectual impairment. As a simple,
and serum calcium are helpful. When planning
fast, cheap, sensitive, and specific screening
complex or invasive investigations, following
model is the combination of the “clock draw”
principles need careful evaluation:25
(in which the patient is asked to draw a clock
™™ Patient’s general health: Do patients
face, with all the numbers placed properly, the
have the physical and mental capacity to
two clock hands positioned at a specified time,
tolerate the proposed investigation? For
(e.g. 10 minutes before 2.00) and the “three-
example, an elderly with knee joint arthritis
item recall” (i.e. India, politics, black; Table
may not be able to perform exercise
27.14), is fairly quick and has reasonable test
ECG; or, an elderly with phobic disorder
characteristics. When the patient is able to recall
(claustrophobia) may not be a suitable
all three items after 3 minutes, the likelihood
candidate for MRI investigation.
ratio for dementia is 0.06. Conversely a markedly
™™ Whether the investigation will alter
abnormally drawn clock is associated with
management: Would the patient be fit for
likelihood ratio of 24.2 When patients fall into
or benefit from the treatment that would be
an intermediate range, further testing with the
indicated if investigations proved positive?
“Mini-Mental State Questionnaire” (i.e. MMS-
The presence of co-morbidity is more
Table 27.14)26, or other instruments can be used.
important than age itself in determining
a patient’s likely benefit from specific
interventions. The more pathogenesis a Functional Evaluation (Table 27.15)
patient has, the less likely he/she will be able Functional evaluation measures a patient’s
to withstand an invasive or an aggressive ability to manage tasks of every day life.
intervention. For example, noninvasive Traditionally, it has focused on those skills that
workup, such as CT coronary angiography, relate to self-care, household management,
or pharmacological stress echocardiography and mobility.
(perfusion imaging with real-time contrast 1. Activities of Daily Living (ADL)—(mnemonic
echocardiography for detecting coronary “DEATH”): These include patient’s ability to

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 260  Section 6: Geriatric Health
TABLE 27.14  A Practical adaptation of MMS questionnaire
Introduction
‘I’d like to ask you some questions about your health.’
‘What’s your sleep been like?’ ................. ‘Your appetite?’ .................
‘Your interest?’ ................. ‘Your energy?’ ................. ‘Your concentration?’ .................
‘What is your memory like these days? Do you mind if I test it?’
Memory registration
‘What I want to do, is given you three things I want you to try to remember for me. First I want you to
repeat them, and then in a few minutes I’ll ask you how many you can recall. Here are the three things
I want you to remember for me.’
‘India, politics, black”.
-/3 ‘Can you repeat them for me?’ (Score number of attempts required -/3, e.g., CORRECT FIRST TRY =
3; SECOND TRY = 2; THIRD TRY = 1)
‘Good, now can you try to remember those three things for me, because I’m going to ask you to recall
them shortly. But first I’d like to get you to do some things that might interfere with your memory.’
Attention and concentration
‘First I’d like you to count out loud from 1 to 20.’ .................
‘Now could you count backwards from 20 to 1.’ .................
‘Next can I get you to spell the word WORLD for me?’ ................. WORLD
-/5 ‘Now can you try to spell WORLD backwards for me?’ _D_L_R_O_W
Memory recall
‘Now what were those three words I asked you to remember for me?’
-/3 --/3 SPONTANEOUS RECALL: ................. India ................. Politics ................. Black
Optional: Cued recall (................. City, ................. Sport, ................. Color)
Recognition (List four cities, four sports, four colors)
Language
‘Sometimes as people get older they have trouble remembering words, the right word, does that ever
happen to you?’
‘Well, let’s see. What do you call this?’
-/1 ................. PEN (Optional more difficult items ................. Cap ................. Point)
................. WATCH (Optional difficult items ................. Strap ................. Winder)
‘Can I get you to repeat a sentence, exactly as I say it?’
-/1 NO IFS, ANDS OR BUTS .....................................................................................
‘Can I get you to do three things with this envelope?’
-/ ‘PICK IT UP WITH YOUR LEFT HAND ................., FOLD THE ENVELOPE
IN HALF ................., and PUT THE ENVELOPE ON THE FLOOR’.................
‘Can you read what’s written on the envelope and do what it says?’
-/1 ‘CLOSE YOUR EYES’ (Written in large letters)
‘Can you write a sentence for me on the back?’
-/1 SENTENCE (should contain subject and object and make sense)
Orientation
‘Can you put your address on the envelope?
-/5 NUMBER ..........., STREET ..........., SUBURB/CITY ..........., STATE ..........., COUNTRY ...........
‘Can you put today’s date on the back?’
-/5 DATE ................., MONTH ................., YEAR ................., DAY ................., SEASON ..................
Visuospatial skills
‘Can you make a copy of this figure for me?’
-/1
-/30 Total Score: Probable cognitive impairment <24
Definite cognitive impairment <17

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 Chapter 27: Comprehensive Geriatric Assessment 261
Table 27.15  Functional geriatric screening instrument
Assessment Procedure Abnormal Action
Do you have difficulty with eyesight? Yes Refer
Jaeger Card or Snellen chart Can’t read 20/40
Test each eye (with glasses)
Whisper short sentence form 6–12 inches (out if view) Unable to hear Cerumen check
or audiometry Refer
“Touch the back of your head with your hands” Unable to do either Further examination
“Pick up the pencil” Consider occupational
therapy?
“Rise from your chair (do not use arms to get up), Observed problems, or Formal balance and gait
walk 10 feet, walk back to the chair, and sit down” unable to perform in <15 evaluation; further exami­
seconds nation; home evaluation
and physical therapy
“Have you had any falls in the last year?” “Do you Yes Formal balance and gait
have trouble with stairs, lighting, bathroom or other Yes to any evaluation
home hazards?” Home evaluation, physical
therapy
Body mass index <21 or weight loss exceeding 5% Yes to either Nutrition evaluation
“Do you have a problem with urine leaks or Yes Incontinence evaluation
accidents?”
“Over the past month, have you often been bothered Yes to either Geriatric Depression
by feeling sad, depressed, or hopeless?” Scale or other depression
“During the last month, have you often been bothered assessment
by little interest or pleasure in doing things?”
Name Three objects: ask again in three 3 minutes Unable to recall Mini-Mental State
Examination
Do you have problems with any of the following areas? Who assists? Do you use devices to help you? (For
“yes” answers, consider referral to occupational therapy, physical therapy, social services)
– Strenuous activities (e.g. fast walking, bicycling) –  Transferring out of bed
– Cooking – Dressing
– Shopping –  Using the toilet
– Heavy housework (e.g. washing windows) – Walking
–  Doing laundry –  Bathing (sponge bath, tub, shower)
–  Transportation by driving or bus
–  Managing finances

perform basic, personal activities of daily life:
Dressing, Eating, Ambulating (i.e. all forms of
mobility: bed mobility; transfers, e.g. bed to
chair, chair to toilet, and bathroom; walking
with or without assisted device on level
ground and climbing steps or stairs; balance;
wheel chair movements), Toileting, Hygiene
(e.g. bath, grooming)
2. Instrumental Activities of Daily Life
(IADL)—(mnemonic “SHAFT”): These
include patient’s ability to perform more
complex task required for independent
living, the instrumental activities of daily
living: Shopping, House work, Accounting
(e.g. banking, paying bills, financial affairs),
Food Preparation (e.g. cooking), Transport
(e.g. by bus, taxi, own car).
3. Information about function can be used
to determine the need for therapeutic
interventions and need for support. In
general, many persons who need help
with ADL can live at house with caregivers,
while those who need help with IADL may
need placement in institutions.
The simple functional geriatric screening
(Table 27.15) developed by Lachs and Moore27,
in addition to ADL and IADL evaluation, also
looks for evidence of health problems that

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 262  Section 6: Geriatric Health
affect functions; sensory impairment, limited
upper extremity range of motion, mobility,
falls, weight loss, incontinence, depressed
mood and cognitive impairment.
Through such an assessment, asymptomatic
illness may be detected and a health maintenance
programme planned. A problem list (as in the
Weed’s system of records) and diagnosis can be
formulated. Rationale therapy can be instituted.
Referral to the institutions, physiotherapists,
medical social workers and nursing homes may
be required.
Advance Directive28
Many older patients have definite ideas about
what they want from their doctors and firm
attitude about screening, life prolongation,
willingness to undergo medical testing and
use of medications or invasive procedures.
Knowing about such values and goals early
helps the physician to focus on suitable
management strategies.29
If an “advance directive”, i.e.—“a written
document, completed by a competent person,
that aims to guide health care decisions in the
event that the person should become unable to
communicate medical preferences or participate
in medical decision making” - has been executed,
it should be documented in the medical records
and the physician should proceed accordingly.
On many occasions, documented written
evidence is not available30, but “instructions
directives”, indicating the type of treatment or
the treatment interventions that the person
would want in various clinical situations, made
either informally, through oral instructions
given to family members, friends, caregivers,
or formally in a written “living will” is available.
Another type of advance directive is
“surrogate or proxy directive”, in which the
person authorizes someone who takes health
care decisions on his/her behalf if he/she
becomes unable to do so.
Besides oral and written documents, audio
taped, video taped discussions of person’s
advanced directives are in force.31
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The early elicitation of a patient’s preferences
and values can often help both physicians and
families to set priorities, deciding what specific
evaluations and therapies are most likely to
provide benefit, taking into considerations
other aspects like life expectancy, the status
of the specific disease, and effectiveness of
therapeutic interventions.
Conclusion
A comprehensive geriatric assessment reflects
a structured approach using standardized
protocols. It identifies clinical problems,
including disability and psychological issues.
More importantly, it helps in the assessment of
risk of preventable disorders and adverse events.
Thus, in comprehensive geriatric assessment,
the physician endeavors to see not just the
isolated problem, but also how the older person’s
problem fits in to the larger context of their life.
Besides working with the existing
community service staff, the physician needs
to develop multidisciplinary care plan for an
integrated approach with other services and
health professionals for optimum care and
improved quality of life.
Improving geriatric education in family
practice residencies will require greater
emphasis on faculty development and
integration of geriatric principles throughout
family practice residency education.
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Am Fam Physician, 2012;85(12):1150–6.
[PMID: 22962895: Abstract].
20. Mary E.T. Preventing falls in elderly persons.
NEJM, 348, 1;2003.
21. Runge M. Diagnosis of the risk of accidental falls
in the elderly. Ther Umsch, 2002;59(7):351–8.
[PMID: 12185951: Abstract].
22. Bree Johnston et al. Geriatric Disorders. In:
Stephen J (Ed.). Current Med Diag and Treat
48th edn. 2009;64.
23. Flanagan PG, et al. The evaluation of screening
tests in a Geriatric Day Hospital Assessment
Clinic. Irish Journal of Medical Science,
1988;157(5):142–5.
24. Colgan J, et al. The routine use of investigations
in elderly psychiatric patients. Age Ageing.
1985;14(3):163–7.
25. Colledge NR. Frail older people. In: Haslett
C. et al. Davidson’s Prin. And Pract. Of Med.
Churchill Livingstone 19th edn. 240–41.
26. John Murtagh. General Practice. McGraw Hill
Book Co. Sydney 1996:47.
27. Lyons WL, et al. Geriatric Medicine. In: Tierney
LM Jr. Current Med Diag & Treat 14th edn.,
2001;49.
28. Web sites: http://www.direct.gov.uk/en/
G overnmentcitizensandr ights/D eath/
Preparation/DG_10029683
http://depts.washington.edu/bioethx/topics/
advdir.html
h t t p : / / w w w . a m e r i c a n g e r i a t r i c s . o r g /
education/forum/advance.shtml
29. Gross. What do patients express as their
preferences in advance directives? Arch of Int
Med, 158 (Issue:4):363–365
30. Doorenbos, Ardith Z., Nies, Mary A. The Use
of Advance Directives in a Population of Asian
Indian Hindus Transcult Nurs, 2003;14:17–24
31. Elisabeth A. et al. Impact of Advance Directive
Videotape on Patient Comprehension and
Treatment Preferences. Arch Fam Med, 1996;
5(4):207–12.
 Management of

28 Common Geriatric
Problems

“When a 100-year-old man finishes a marathon*, as happened last year, we have to rethink conventional
definitions of what it means to be ‘old’.
Margaret Chan, Director General of the WHO,
World Health Day 2012, 03 April 2012, Geneva.
“We cannot heal the old age, but let us protect it, promote it and prolong it.”
Sir J Ross.

The “Age Wave” and long-term care, prevention of disease, and

Aging of the population is one of the most
important developments that took place at the
turn of the 20th and 21th centuries. Longevity
has increased due to significant progress in
medical technology, which has contributed in
promoting and extending survival rates from
several life-threatening diseases.
The World Health Organization (WHO)
designated the year 1999 as the “International
Year of the Older Persons” (IYOP), and to
underline this aspect, the theme of the World
Health Day 1999, in the IYOP was designated
as “active aging makes the difference”,
emphasizing thereby the importance of
continued participation in social, economic,
cultural, spiritual and civic affairs, and not
just the ability to remain physically active or
to participate in the labor force.
In response to these public health challenges
posed by the aging and the aged population
in the areas of health services, rehabilitation
other activities, WHO, in April 1995, launched
a program on “aging and health”, with the
theme of promoting “healthy aging”. Further, to
underscore the importance of aging and health,
the WHO on its World Health Day 2012, focused
its theme as “Good health adds life to years”.
The growing evidence substantiates the fact
that health promotion and preventive health
approaches are effective in improving overall
health and well-being, reducing the burden of
chronic disease and injury. Thus, investing in
health and its promotion throughout the life
span is the one of the holistic ways to ensure that
more people will reach old age in good health
and will be capable of contributing to the society
intellectually, spiritually, and physically.
However, the magnitude of healthcare
delivery to the elderly are so extensive that “the
whole world resources have to be geared up
towards meeting their challenges”1 of keeping
the elderly diseases free, productive and self-

*100-year-old Fauja Singh, a British citizen who was born in India in April 1911, “The Turbaned Tornado,”
as he’s been nicknamed, finished Toronto’s waterfront marathon Sunday evening (Sun, Oct 16, 2011), in
8 hours, 11 minutes and 5.9 seconds, securing his place as the oldest person—and the first centenarian—to
ever accomplish a run of that distance.

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 Chapter 28: Management of Common Geriatric Problems 265
sufficient. Recently, numerous developed
countries have started to develop long-term care
service programs to the elderly that will both
meet the rising needs for this service and be cost-
effective. The WHO in its “Active aging” series
states, “In order to prepare for unprecedented
population aging now, it is of utmost importance
that health systems in developing countries are
prepared to address the consequences of these
demographic trends”, and launched “toward
age friendly primary health care” project, with
an aim to sensitize and educate primary health
care providers about the specific needs of their
older clients.2
Paucity of Geriatric Care
Although, living longer is a true privilege, care
for the graying population, suffering from
chronic and disabling diseases will impose
enormous challenges to healthcare systems
and geriatric education.3
Reuben et al4 pointed out that the rapid
growth of the older population in the next
40 years (as baby boomers age*) would have a
dramatic impact on the number of physicians
needed. Further, the marked increase in the
elderly population expected over the next
few decades will place a heavy strain on the
current healthcare system. The Institute of
Medicine has noted challenges related to the
preparation of a geriatric workforce due to
lack of faculty, inconsistent curricula, and few
training opportunities.5
Many studies conclude that despite a
rapidly aging population, a tremendous
shortage now exists of faculty with interest and
expertise in geriatrics. The persistent difficulty
in finding physicians who are interested
in geriatrics suggests that the number of
physician geriatricians will probably remain
lower than optimal.6
*Although, an official definition of the” baby boom” does not exist, consensus describes a period of
increased birthrates lasting from 1946 to about 1965 as the baby boom.
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Geriatric Care and Family Physician
In advanced countries, approximately one-half
of the ambulatory primary care for adults older
than 65 years is provided by family physicians.7
In India, about 75% of the elderly reside
in rural areas. At present, most of the geriatric
outpatient department services are available
at tertiary care hospitals. Also, most of the
government facilities such as day care centers,
old age residential homes, and counseling
and recreational facilities are urban based.
Factors such as a lack of transport facilities
and dependency on somebody to accompany
an elderly person to the health care facility
impede them from accessing the available
health services. Therefore, for timely and
proper treatment, peripheral health workers
and community health volunteers should
also be trained to identify and refer elderly
patients. Further, to ensure good quality
geriatric healthcare services at the primary
level, and to improve the outcomes of geriatric
ambulatory care, it is prudent that geriatric
healthcare services be made a part of the
primary healthcare services.8 This calls for
specialized training of primary health care
professionals. The defining features of
primary care (i.e. continuity, coordination,
and comprehensiveness) are well suited to the
care of chronic illness.
Family practice residents need to be prepared
to take care of the geriatric population. To
accomplish this task, Li I et al9 suggest, “Faculty
development to enhance the number of faculties
who can teach geriatrics and broadening the
exposure of residents to the elderly in a variety
of settings will be important to ensure that future
generations of family physicians are adequately
equipped to care for the geriatric population”.
This shortage presents an opportunity for
the family physicians to once again fulfill its
 266  Section 6: Geriatric Health
mission of providing care to a population that is
underserved.10 A rapidly growing body of health
service research points to the design of the
care system, not the specialty of the physician,
as the primary determinant of chronic care
quality.11 In a recent study conducted by Moore
A et al,12 substantiated the fact that a core family
health team, compromising a family physician,
nurse practitioner, registered practical nurse,
and a visiting geriatrician, is ideally positioned
to deliver shared care for the frail elderly, its
outcome being a short referral time and easy
access, which might allow seniors to remain in
their environment of choice. Therefore, the role
of trained and certified family physicians in the
health care management of the elderly cannot
be overemphasized.
Atypical Symptoms (Table 28.1)
A striking feature of disease in the elderly is that
it is very often multiple. Once people are in their
60s and 70s, they commonly show evidence of
several different pathological processes like
diabetes, hypertension, metabolic syndromes,
Table 28:1  Characteristics of disease in old age
• Non-specific presentation of disease: Typical
signs and symptoms may be absent. Perception
of pain is altered. (e.g. MI without chest pain. The
pyretic response is blunted so that infection may
not be obvious at first (e.g. chest infection without
cough or sputum)
• Multiple pathologies: One problem may have
several causes. (e.g. fall and unsteadiness
because of osteoarthritis, poor vision and postural
hypotension).Treating one alone may do little
good; treating all may be of much benefit
• Late presentation of illness: Many elderly accept
ill health as a consequence of aging and thus
may tolerate symptoms for lengthy periods before
seeking medical advice
• Rapid deterioration can occur if disease is
untreated. Complications are common
• More time is required for recovery
• Impaired metabolism and excretion of drugs. Dose
may need lowering
• Social support, e.g. relations with family, friends
and neighbors; physical, emotional and financial
aids are central in aiding recovery and return
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depression, dementia, malignancy, etc. An
unfortunate consequence of multiple diseases
is that the symptoms and signs of a new disease
may be wrongly attributed to the old disease
already diagnosed.
When dealing with younger patients, it is
customary to try to explain every symptom,
sign and abnormal laboratory finding in terms
of a single pathological process. This approach
is completely inappropriate in the old.
In the elderly patients, disturbance of
the function in one system is commonly
associated with adverse effects on other
organs. Further diagnosis may be delayed or
missed due to complicating factors, such as
iatrogenic illness caused by side-effects of the
drugs and polypharmacy. In old people, one
has to be more careful to ascribe symptoms
to a single disease condition without looking
for other possible causes for the symptoms
and for hidden complicating factors like
hypothyroidism and malignancy.
Some characteristic features which generally
lead to atypical presentations of illness, causing
delay or missed diagnosis in the elderly include:
™™ The aliments are usually insidious in
origin, gradually progressive, long drawn,
irremediable and natural
™™ They have limited intellectual, functional
reserve and impaired reserves
™™ Their lifestyle is altered
™™ They are accident-prone
™™ They are more vulnerable to environmental,
pathologic or pharmacological insults.
Therefore, a better understanding of the
processes through which elderly individuals
perceive, evaluate, and act on symptoms
will enable physicians to respond more
appropriately to the rational management of
the older patients.
Physician’s Role
Family physicians or primary care physicians
usually initiate an assessment in their offices
 Chapter 28: Management of Common Geriatric Problems 267
and inpatient units. Nevertheless, most
geriatric assessments, performed under
the constraints of time tend to be less
comprehensive.
Whereas the standard medical evaluation
works reasonably well in most other patients,
it tends to miss some of the most prevalent
problems faced by the elder patient - often
referred to as the “Five I’s of Geriatrics”,
namely, intellectual impairment, immobility,
instability, incontinence and iatrogenic
disorders.
It’s not uncommon for elderly patients
to have multiple chronic problems and to be
taking multiple medications from multiple
doctors because of the “vague” nature of their
complaints. In addition to medical diseases,
psychological, social, cognitive, and functional
issues influence the health of older persons.
Ideally, under these circumstances,
an interdisciplinary team—representing
medicine, psychiatry, social work, nutrition,
physical and occupational therapy and others
performs a detailed assessment, analyzes the
information, devises an intervention strategy,
initiates treatment, and follow-up on the
patient’s progress.
Taking cognizance of the distinct recognized
needs of the elderly, geriatric assessment which
is sufficiently flexible in scope and adaptable
in content to serve a wide range of patients has
been developed (Table 28.2), which utilizes
specific tools to help determine patient’s status
across several different dimensions, including
assessment of medical, cognitive, affective,
social, economic, environmental, spiritual, and
functional status. Family physicians can improve
the care that they provide for their older patients
by using the following organized approach to the
varied aspects of geriatric health.
Although family physicians in practice
today feel overworked and overwhelmed by an
influx of elderly patients with complex health
*Ref. Table 27-1, Chapter 27.
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Table 28.2  The four stage ‘geriatric process’
• Assessment:
–– Assessment of health: By core geriatric team;
‘getting to know’ the patient as an individual;
to build mutual trust and friendship
–– Assessment of function: In particular ‘activities
of daily living
–– Assessment of mental function: By using “abbre­
viated mental test score’ or “Folstein mini-mental
examination’; and ‘geriatric depression scale’
–– Assessment of cultural, educational back­
ground; protection of patients’ autonomy;
involvement of family in planning care
• Agree objectives of care:
–– What does the patient want and what is
feasible: A dialogue and negotiation between
doctor who knows what could be effectively
done and the patient who decides what should
be done
• Formulating a management plan:
–– Using therapeutic and prosthetic interventions.
• Regular review:
–– Regular review of patient’s progress; conduc­
ting multiprofessional meetings; reha­bilitation;
review needs of family and other members;
implementation of altered plans.
Source: Evans JG. Medicine in old age. In: Warrell DA et al.
Editors. Oxford TB of Medicine, 4th ed. Vol. III: 1388.
care needs, the fact is that in today’s expanding
but fragmented healthcare system, family
physicians simply can’t meet expectations
without drafting other members to join the
practice team. As stressed earlier, a core family
health team, compromising a family physician,
nurse practitioner, registered practical nurse,
and a visiting geriatrician, is ideally positioned
to deliver shared care for the elderly. Team-
based care at its best should offer a better
patient experience, improved patient health
and reduced healthcare costs.
With the above caveat in mind, the
following points are useful in providing
appropriate interventions and improve quality
of life for geriatric patients:
™™ Family physicians must do a comprehensive
geriatric assessment* (physical, mental and
 268  Section 6: Geriatric Health
socioeconomic) of their patients with social
attention to the problems of the elderly
™™ They must diagnose and treat various
systemic and mental diseases, with special
emphasize on atypical presentations of
illness in the elderly
™™ They must provide psychological support
™™ They must help in accident prevention and
guide in lifestyle and diet management
™™ They must encourage domiciliary treatment
™™ Medicines must be cost effective
™™ They must educate patients and their
family members the disease process and
its clinical course
™™ They must be able to organize inter­
disciplinary care and be a part of a critical
care team.
Major Manifestations of Common
Geriatric Problems
Neuropsychiatric Problems
Confusion and forgetfulness: Although, aging
is normally associated with some decline in
specific areas of cognitive performance (termed
commonly as benign senile forgetfulness), the
elders normally retain near-full capacity
to learn and remember new information,
perform problem-solving and communicate.
The elderly may have deficient short-term
memory, i.e. they may completely forget what
happened yesterday or a few hours back; but
long-term memory, i.e. events which occurred
years or decades ago is retained. Therefore,
confusion and disorientation, i.e. a pattern of
memory loss that interferes with the elder’s
capacity to perform daily activities, are not a
normal aging phenomenon. They are almost
always manifestations of pathological process
(e.g. cerebral hypoxia due to congestive cardiac
failure, myocardial infraction, or metabolic
disturbances), and some of them may even
manifest as medical emergencies (e.g. infection,
stroke, intoxication, or adverse drug effects).
*Ref. Chapter 27.
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Dementia, depression, and delirium: They may
occur individually or may co-exist. Dementia
is an acquired, persistent and progressive
impairment in intellectual function, with
compromise of memory and at least one other
cognitive domain.
Suitable office procedures, such as “Criteria
for Dementia” (Table 28.3) and models like
“Mini Mental State examination”* are available
for initial screening of dementia.
Table 28.3  DSM-IV criteria for the diagnosis of
dementia of the Alzheimer’s type
A. The development of multiple cognitive deficits
manifested by both:
1. Memory impairment (impaired ability to learn
new information or to recall previously learned
information)
2. One or more of the following cognitive
disturbances:
a.  Aphasia (language disturbance)
b. Apraxia (impaired ability to carry out motor
activities despite intact motor function)
c. Agnosia (failure to recognize or identify
objects despite intact sensory function)
d. Disturbance in executive functioning (i.e.
planning, organizing, sequencing, abstracting)
B. The cognitive deficits in criteria A1 and A2 each
cause significant impairment in social or occupational
functioning and represent a significant decline from
a previous level of functioning.
C. The course is characterized by gradual onset and
continuing cognitive decline.
D. The cognitive deficits in Criteria A1 and A2 are not
due to any of the following:
1. O ther central nervous system conditions
that cause progressive deficits in memory
and cognition (e.g. cerebrovascular disease,
Parkinson’s disease, Huntington’s disease,
subdural hematoma, normal -pressure
hydrocephalus, brain tumor)
2. Systemic conditions that are known to cause
dementia (e.g. hypothyroidism, vitamin B
or folic acid deficiency, niacin deficiency,
hypercalcemia, neurosyphilis, HIV infection)
3.  Substance-induced conditions
E. The deficits do not occur exclusively during the
course of a delirium.
F. The disturbance is not better accounted for by
another Axis I disorder (e.g. Major depressive
episode, schizophrenia).
 Chapter 28: Management of Common Geriatric Problems 269
A large majority of patients with dementia
have Alzheimer’s disease, which presents early
with problems in memory and visuospatial
abilities (e.g. becoming lost in familiar
surroundings, inability to copy a geometric
design on paper). Personality and behavioral
changes usually develop later.
Depression: 13 Although, depression is a
common problem in older adults, it is often
undetected, undiagnosed, untreated, or
undertreated.
Risk factors for developing depression
after age 65 years are similar to those in
younger individuals and include being female,
unmarried and poor, having chronic physical
illness, social isolation, a history or family
history of depression.
Additional risk factors that are particularly
important in older adults include loss and grief,
loneliness and care-taking responsibilities.
Other risk factors that increase the likelihood
of depression in the medically-ill elderly
include presence of cognitive impairment,
age greater than 75 years, poor social support,
active alcohol abuse and lower educational
attainment.
Geriatric patients with depression are more
likely to have somatic complaints (e.g. fatigue,
anorexia, body aches and pains), less likely
to report depressed mood, and more likely to
experience delusions (e.g. thoughts such as, “I
am going to die”, “world is ending”) than younger
patients. Other common feelings and expressions
are “I am not needed”, “nobody needs me,” or “I
feel I am just in everyone’s way.” Such utterance
may indicate a patient’s loss of self-worth or
sense of loneliness. In addition, depression
may be an early symptom of neurodegenerative
condition, such as Parkinson’s disease, multiple
sclerosis, or dementia.
*An aide-memoire to help remember the common causes of delirium is HIDEMAP: i.e. H – hypoxia, I –
infection, D – drugs, E – endocrine, e.g. diabetes, M – metabolic, e.g. hyper/hypocalcemia, A – alcohol,
P – psychosis.
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It’s very important for family physicians
to recognize depression early and offer
therapy, because suicide, the most dreaded
complication of depression has its highest
risk in the geriatric age group. 14 However,
despite the high epidemiological relevance of
depressive disorders in daily clinical practice,
they are insufficiently diagnosed. Older
adults often do not directly or spontaneously
report thoughts of suicide, which can impede
suicide prevention efforts. Therefore, the
use of additional approaches to suicide risk
detection is needed, including the use of
screening tools. Therefore, for initial screening
for depression, the US. Preventive Services
Task Force has proposed simple “two-question
screen” aiming at finding depressive core
symptoms, which consists of asking “Over the
past 2 weeks, have you felt down, depressed,
or helpless?”, and “Over the past 2 weeks, have
you felt little interest or pleasure in doing
things?” The two screening questions showed
a sensitivity and specificity of 97%.15 Positive
response can be followed up with more
comprehensive interviews, such as “Geriatric
depression scale” (Table 28.4).
Delirium:* It’s an acute confusional state—a
syndrome which typically develops over a
short time, becoming clinically apparent over
a few minutes, hours, or days, with the level
of consciousness, cognition, and perpetual
disturbances such as space or size distortion or
confusion tending to fluctuate (Table 28.5). It is
often the only apparent clinical manifestations
of a serious illness. For example—myocardial
infarction or pulmonary embolus in elderly
may present initially with confusion in the
absence of chest pain or dyspnea. Similarly,
abdominal catastrophes like bowel infarction,
perforation, peritonitis may be heralded by
 270  Section 6: Geriatric Health
Table 28.4  YESAVAGE Geriatric Depression Scale16 One of the most frequent causes of
(Short form)
delirium in the elderly is overmedication,
1. Are you basically satisfied with your life? (No) the use of a new drug, or the discontinuation
2. Have you dropped many of your activities and of a medication known to cause withdrawal
interests? (Yes)
symptoms. Hence, review of all the medications
3. Do you feel that your life is empty? (Yes)
4. Do you often get bored? (Yes) (Table 28.6), including OTC drugs, is a crucial
5. Are you in good spirits most of the time? (No) step in the management of delirious patient.
6. Are you afraid that something bad is going to Family physician must have a high degree
happen to you? (Yes)
of suspicion to recognize and evaluate acute
7. Do you feel happy most of the time? (No)
8. Do you often feel helpless? (Yes) confusion, or any unexplained behavioral
9. Do you prefer to stay home at night, rather than changes as possible delirium and look for
go out and do new things? (Yes) an organic cause and initiate therapy at the
10. Do you feel that you have more problems with
memory than most? (Yes)
earliest to prevent usually reversible morbidity
11. Do you feel it is wonderful to be alive now? (No) and mortality.
12. Do you feel worthless the way you are now? (Yes)
13. Do you feel full of energy? (No) Psychological Problems and Elder
14. Do you feel that your situation is hopeless? (Yes)
15. Do you think that most persons are better off than Abuse
you are? (Yes)
Psychological problems in the elderly are
Score one point for each response that matches the frequent and arise from many factors such as:
yes-or-no answer after the question ™™ Failing memory, vision and hearing, which
Scores: Normal 3 +/- 2; Mildly depressed: 7+/-3; Very cause embarrassment
depressed: 12+/-2
™™ Confinement at home due to immobility
Table 28.5 Differentiating features of delirium and
or disability
dementia
™™ Chronic unrelieved pain
Features Delirium Dementia
™™ Feeling of insecurity due to financial
Onset Acute Insidious difficulties
Course Fluctuating Progressive
Duration Days to weeks Months to ™™ Loss of self-respect and prestige
years ™™ Diseases like diabetics, hypothyroidism,
Consciousness Altered Clear parkinsonism
Attention Impaired Normal, except
™™ Drugs like opiates, benzodiazepines,
for severe
dementia corticosteroids
Psychomotor Increased or Often normal ™™ Loss of work and retirement.
changes decreased Rarely
Elders may lack the ability to put their
Reversibility Usually
feelings into words, and hence, may lack the
confusion in the very old. Even when delirium ability to seek help and to identify the problem.
is caused by less serious conditions, like mild The rapid pace of changes in the family
dehydration, medications, pneumonia, or structure, which has traditionally been the
sepsis, it can lead to significant reversible co- main support for the elderly, has also proved
morbidity and excess disability in the elderly. upsetting for them.
When the underlying cause is identified and Besides, psychological (or emotional)
properly managed, confusion and other abuse (Table 28.7),17 i.e. insulting, threatening,
cognitive disturbances associated with humiliating, intimidating, or harassing through
delirium are usually reversible and improve words or actions, ignoring the elder, giving
quality of life. silent treatment, or isolating them from family

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 Chapter 28: Management of Common Geriatric Problems 271
Table.28.6  Toxic causes of delirium
• Substance intoxication—Alcohol, heroin, phency­
clidine, amphetamine, cannabis, and LSD
• Medication-induced delirium
–– Anticholinergics (e.g. tricyclic antidepressants)
–– Antihistamines (e.g. diphenhydramine)
–– Narcotics (e.g. opioids, meperidine)
–– Sedative hypnotics (e.g. benzodiazepines)
–– Histamine-2 (H2) blockers (e.g. cimetidine)
–– Corticosteroids
–– Centrally acting antihypertensives (e.g.
methyldopa, reserpine)
–– Anti-Parkinson drugs (e.g. levodopa)
• Substance withdrawal from alcohol, opioids, and
benzodiazepines
Table 28.7  Types of elder abuse
• Physical Abuse: Inflicting, or threatening to inflict,
physical pain or injury on a vulnerable elder, or
depriving them of a basic need.
• Emotional Abuse: Inflicting mental pain, anguish,
or distress on an elder person through verbal or
nonverbal acts.
• Sexual Abuse: Non-consensual sexual contact
of any kind.
• Exploitation: Illegal taking, misuse, or concealment
of funds, property, or assets of a vulnerable elder.
• Neglect: Refusal or failure by those responsible to
provide food, shelter, health care or protection for
a vulnerable elder.
• Abandonment: The desertion of a vulnerable elder
by anyone who has assumed the responsibility for
care or custody of that person.
• Self-neglect: An inability to understand the
consequences of ones own action or inaction, which
leads to or may lead to harm or endangerment.
members, friends, or their regular activities,
cause mental or emotional pain, distress,
suffering, or anguish; and its incidence is on
the rise in the elderly population.18,19 This may
be unknowingly or purposely done by family
members or any person that is caring for an
elder. These factors frequently result in social
withdrawal, loss of emotional support, feelings
of loneliness and neglect, anxiety, depression,
and at times a tendency towards suicide.
*Any disorder of cognition that cause decreased mental functioning (such as problems with attention,
concentration, thinking, judgment, emotional liability) caused by permanent or temporary brain
dysfunction and characterized especially by dementia.
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Table 28.8 lists questions that are helpful to
elicit a history of elder abuse.20
Family physicians should be aware of the
differential diagnosis of psychiatric disorders
in the elderly and not simply label patients as
`senile’. The elderly are subject to acute brain
syndromes* caused by physical illness or drug
toxicity. When acute brain syndromes are
excluded, the illness is likely to be a functional
one—the most common functional illness
in old age is depression or a chronic organic
brain syndrome due to degenerative disease,
nutritional deficiencies, endocrine disorders,
or neoplasms.
Family physicians, besides initiating
therapy and referral to other members of the
team, can try to arrange activities to boost the
patient’s morale and self-confidence.
The benefit of an empathetic therapist
can do much to supplement anti-depressant
medication with careful and regular monitoring,
and helping the elder to find ways to manage
many of the psychological problems of growing
older. Charitable clubs, religious organizations,
developing a secondary career and hobbies
are very helpful areas for family physicians to
counsel elderly for gainful involvement.
Cardiovascular Problems
The prevalence of cardiovascular diseases in
the elderly population has increased due to
increase in the worldwide aging population,
and the aged population itself becoming older
with more people surviving to advanced ages.
Presentations of cardiac illness often differ
from those in a younger population. Most of
the available data on therapy and prognosis
do not apply to contemporary practice, so that
clinical decisions are often extrapolated from
information acquired in younger patients.
 272  Section 6: Geriatric Health
Table 28.8  Questions to elicit history of elder abuse Table 28.9  Common age related changes associated
with cardiovascular disease
1.  Has anyone ever hurt you?
2.  Has anyone ever touched you without permission? Age-Related Changes Cardiovascular Disease
3. Has anyone ever made you do things you didn’t • Decreased heart rate • Sinus pauses
want you to do? response • Second and third
4. H as anyone taken anything of yours without • Longer P-R intervals Degree AV block
asking? • Right bundle branch • Left bundle branch
5.  Has anyone ever scolded or threatened you? block block
6. Have you ever signed any paper that you didn’t • Increased atrial • Atrial fibrillation
understand? ectopy • Sustained ventricular
7. Is there anyone at home you are fearful of? • Increased ventricular tachycardia
8.  Are you alone much? ectopy • Decreased systolic
9. Has anyone refused to help you to take care of • Altered diastolic Function (i.e. ejection
yourself when you needed help? function fraction)
• Aortic sclerosis • Aortic stenosis,
• Annular mitral Aortic regurgitation
Clinical evaluation of elderly patients calcification • Mitral regurgitation
is often hampered by multiple co-existing
diseases involving other organ systems,
problems in reporting symptoms, and Table 28.10 Common cardiovascular diseases in
associated functional and structural changes of elderly
aging that may mimic or mask cardiovascular • Isolated systolic hypertension
disease. • Orthostatic hypotension
With advancing age, the heart undergoes • Congestive heart failure
• Aortic stenosis
subtle physiologic changes, but the rate of • Mitral annular calcification
this change or decline in cardiovascular • Heart block
function varies greatly among individuals. • Sick sinus syndrome
• Atrial fibrillation
In an otherwise healthy person, the decline • Stroke
is not likely to be of great importance, but
in the elderly, with increasing incidence of
cardiovascular diseases, these age-related Hypertension is more common with
changes (Table 28.9) 21 may compound advancing age, and so are its associated
the problem or its treatment. However, it complications. Therefore, family physicians
is important to differentiate the cardiac must maintain the blood pressure record
manifestations of normal aging (Table 28.10) (Table 28.11). The benefits of prompt treatment
from cardiac disease in the older patient. of both isolated systolic hypertension and
Atherosclerotic coronary heart disease is the combined systolic and diastolic hypertension
most prevalent problem, followed by hypertensive in elderly have now been well documented.
cardiovascular disease. Calcific aortic stenosis is Treatment reduces the risk of transient
the most common hemodynamically important ischemic attack, stroke, angina, myocardial
valvular lesion; surgical correction significantly infarction, and also reduces the risk of vascular
improves the prognosis. Pulmonary embolism dementia and Alzheimer’s disease.
occurs frequently, related to immobilization and Cardiac risk factors like lipid abnormalities,
co-morbidity. Congestive heart failure is both obesity, diabetes, tobacco smoking, and life
under-diagnosed and over-diagnosed. Complete style should be assessed and interventions
heart block and sick sinus syndrome increase initiated. Basic ECG should be recorded and
with age; appropriate pacemaker therapy can exercise ECG done with proper precautions
improve the length and quality of life. in selected patients.

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 Chapter 28: Management of Common Geriatric Problems 273
Table 28.11  American College of Cardiology
Foundation/American Heart Association consensus
document for evaluating hypertension in older patients
• Take at least three different blood pressure
measurements on two different office visits
• Two of those measurements should be obtained
after the patient has been seated comfortably for
at least 5 minutes with the back supported, feet on
the floor, and arm supported in horizontal position,
with the blood pressure cuff at heart level
• Take a blood pressure measurement with the
patient standing for 1–3 minutes, particularly after
a meal, to evaluate for postural hypotension or
hypertension
• The older the patient, the more likely that PAD is
present, so it is important to take an ankle brachial
index (ABI). Diagnose PAD if the ABI is less than
0.90 or 1.4 and higher
• Target systolic blood pressure is =140/90 mm Hg
in patients aged 55–79 years; a systolic blood
pressure of 140–145 mm Hg, if tolerated, can be
acceptable for those older than 80
*Website—http://content.onlinejacc.org/article.
aspx?articleid=1146473
Smoking cessation, regular physical activity
and healthy diet are, as in younger individuals,
appropriate and effective measures for
preventing cardiovascular events in the elderly.
Respiratory Problems
The great reserve function of the lung permits
reasonable physical capacity in healthy
individuals despite aging changes. In principle,
loss of function equivalent to more than one
lung is necessary to impair aerobic capacity
at any age.
Elderly people are subject to the same
respiratory diseases as younger adults but may
manifest them differently. They may present in
atypical ways such as in bacterial pneumonia,
tuberculosis, and asthma, all modified by
anatomical alterations or deterioration of
immunological defence mechanisms.
The normal physiological changes in the
respiratory system with advancing age include
muscle atrophy, increased AP diameter, rigid rib
cage; alveoli become thinner and bronchioles
lose elasticity which decreases exchange of
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gases, impaired diffusion of oxygen, and tissue
hypoxia. The resultant impaired ventilation,
decreased maximal breathing capacity, vital
capacity, residual volume, and functional
capacity (i.e. senile emphysema) leads to
reduced ability to cough, increased susceptibility
to infections such as a cold or pneumonia.
Accumulation of toxic substances over time such
as cigarette smoke or environmental pollutants
may give rise to chronic bronchitis, emphysema,
COPD, bronchogenic carcinoma and interstitial
lung disease.
Associated decreased immune system
functions, decreased resistance to disease,
infection, slowed response to inflammation,
and associated co-morbid chronic diseases
may decrease the efficiency of the respiratory
system even more severely. Thus, the elderly
readily get infected because of reduced
tolerance, lowered vital capacity, and pollution
and co-existing systemic diseases like diabetes.
The elderly are less tolerant to extremes
of temperature and high altitudes. Absence
of signs of inflammation like fever may not
be obvious in elderly even in the presence of
severe infection. Even with healthy lungs the
common age-associated morbidity of spinal
osteoporosis with loss of height profoundly
influences lung volume, oxygenation, and
exercise capacity.
Neurologic conditions may affect the
swallowing mechanism, leading to aspiration
of oropharyngeal contents, which presents as
signs and symptoms localized to the upper
airways, lung parenchyma, or as unsuspected
radiographic findings. Likewise, the only
indicators of heart failure or esophageal reflux
disease may be reported or observed dyspnea
or a cough.22
Adverse reactions to respiratory drugs such
as theophylline (may contribute to insomnia);
oral corticosteroids (worsening glaucoma
control, osteoporosis, and diabetes) and beta-
blockers (worsening asthma, COPD) increase
with age.
 274  Section 6: Geriatric Health
A basic work-up should include chest
X-ray, peak flow rates, blood counts, and
indirect laryngoscope. Spirometry can be
useful in the evaluation of chronic cough,
wheezing, breathlessness or chest pain.
Baseline oximetry should be performed on all
dyspnoeic patients and those with abnormal
spirometry. Persistent hoarseness of voice,
hemoptysis, and cough are indicators of
tuberculosis or malignancy, requiring referral
to a chest physician.
Gastrointestinal Problems (Table
28.12)
Metabolism is reduced, needing supplemental
vitamins and minerals to prevent
malabsorption. Food selection is limited
because of loss of teeth or an improper fitting
denture. Small frequent meals and easily
Table 28.12 Common gastrointestinal problems in
the elderly
• Age-related changes in esophageal function:
GERD
–– Due to: decreased contractile amplitude;
polyphasic waves; incomplete relaxation of the
lower esophageal sphincter and esophageal
dilation.
• Aging-Associated Changes in Colonic Motility:
Common disorders observed:
–– Constipation
–– Diverticular disease
–– Diarrhea
–– Fecal incontinence
• Common causes of diarrhea:
–– Infections
–– Drug-induced diarrhea
–– Malabsorption
–– Fecal impaction
–– Colonic carcinoma
–– Small bowel bacterial overgrowth
–– Diabetic diarrhea
• Less common causes of diarrhea:
–– Celiac disease
–– Inflammatory bowel disease
–– Thyrotoxicosis
–– Pancreatic insufficiency
–– Small bowel tumors
–– Scleroderma with systemic manifestations
–– Amyloidosis with small bowel involvement
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digestible food are to be recommended.
Constipation is common, but before initiating
treatment, the patient’s views and expectation
of ‘bowel normality’ must be elicited, and any
history of recent change in bowel habit must
be further evaluated.
Certain common drugs, like oral iron and
laxative overuse can lead to constipation;
other drug classes that can cause constipation
include anticholinergics, antidepressants, and
anxiolytics, anti psychotics, opiate analgesics,
and antihypertensives. A diet rich in fiber
along with exercise and behavioral bowel
training generally helps relive constipation.
In resistant cases judicial use of mild laxatives
may be indicated.
Any obstruction in the gastrointestinal
(GI) tract must be ruled out, its commonest
cause in the elderly being fecal impaction.
Gastrointestinal bleeding occurs frequently
in elderly people, and aspirin, NSAIDs, and
antiplatelet therapy are associated with an
increased risk of both upper GI and lower
GI bleeding this population. If there are any
signs of malignancy anywhere in G.I. tract, e.g.
dysphagia, malena, lump in the abdomen, or
a feeling of obstruction, the patient must be
referred for its evaluation.
Incontenance and Urogenital
Problems
The age related decrease in the renal function
leads to reduced glomerular filtration rate,
and equations like Cockroft-Gault formula
to estimate creatinine clearance can mislead
in extreme old age; 23 however, a formula
developed by the Modification of Diet in
Renal Disease (MDRD), based on the patient’s
creatinine levels, age, sex, race and serum urea
nitrogen and serum albumin levels, has shown
to be more accurate.24
There is decline in the bladder capacity and
loss of bladder control. The changes in the lower
urogenital tract predispose to incontinence
 Chapter 28: Management of Common Geriatric Problems 275
in the presence of additional pathological,
pharmacological, or physiological insults
usually outside the urogenital tract (Table
28.13). Possible iatrogenic causes must be
reviewed, including diuretics, antidepressants
and sedative drugs. Treatment of the
factors precipitating incontinence such as
infection, stool impaction, hyperglycemia,
hypercalcemia, unrecognized congestive
cardiac failure may restore countenance
without correcting the underlying pathology.
In men, if the postvoid residual urine volume
is more than 150 mL. due to benign prostatic
hypertrophy, surgical intervention may
be indicated. In many instances urinary
incontinence may be a problem only at night.
A range of incontinence pads and holders
are available to the needy disabled elderly
individuals.
Endocrine Problems
Despite age-related changes, the endocrine
system functions well in older people.
However, some changes such as reduced
hormone production, secretion and their
metabolism occur because of destruction of
cells during the aging process and genetically
programmed cellular changes.
Table 28.13  Forms of urinary incontinence
• Acute
–– Transitory due to illness, delirium, epilepsy,
etc.
• Established
–– Infection
–– Functional—difficulty in getting to the toilet
–– Stress—loss of urine on coughing or straining
–– Urge—often due to precipitate bladder
contractions
–– Overflow—secondary to obstruction of bladder
outflow
–– Fistulous—e.g. vesicovaginal fistula
–– Disinhibitory—e.g. in frontal brain damage,
dementia
Ref.—Evans J.G. Medicine in old age. In: Warrell DA et
al. Eds. Oxford TB of Medicine, 4th edn. Vol. III: 1359.
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In the elderly , clinical presentation of
endocrine dysfunction are frequently subtle,
harder to detect than in younger persons and
may be incorrectly linked with other causes,
such as normal aging, other medical disorders
or drug therapy.
The elderly group of people also has
different physiological standards/ranges, and
consequently, results of their investigations
may differ from younger adults. Examples
include a lower cut off level for serum
testosterone in the elderly, and varying values
for Z scores in the diagnosis of osteoporosis.
Also, there is gradual elevation of the fasting
glucose level by 6–14 mg/dL per decade after
age 50 years. It is also common for elders to
have hypoglycemia following meals, as well as
hyperglycemia caused by insulin resistance.
Treatment of endocrine disease also varies
markedly in the elderly. Doses of growth
hormone, thyroxine and insulin are relatively
lower in this age group. Psychosocial factors
unique to the elderly play an important role
in management of endocrine and metabolic
disorders, such as osteoporosis and diabetes,
and should be taken into consideration in the
search for optimal care of such patients.
Adult hypopituitarism, hypothyroidism,
osteoporosis, diabetes mellitus, adrenal
insufficiency, various forms of hypogonadism,
and endocrine malignancies are more frequent
in old age.
Hypothyroidism: In the elderly hypothyroidism
is usually of autoimmune origin, although
previous thyroid surgery and radio-iodine
therapy account for a less proportion. Because
of the frequent atypical symptoms such as
insidious decline in health with psychiatric
manifestations, particularly depression,
hypothyroidism in elderly is difficult to
detect clinically. Serum TSH levels should
be measured at least once in asymptomatic
older people. Thyroid replacement therapy in
elderly needs cautious approach, particularly
 276  Section 6: Geriatric Health
in the presence of coronary artery disease. It is
often necessary to seek the assistance of family
members or visiting nurse to ensure life-long
treatment.
Hypothyroid coma (myxedema coma):
Although, rare in occurrence, this condition
needs prompt diagnosis to avoid potential
lethal complications. It is usually precipitated
by systemic infection, or failure to comply
with treatment. Symptoms such as mental
confusion, severe headache, seizures,
hypothermia are typical presentation. Patients
need to be monitored in ICU with immediate
intravenous  thyroid hormone replacement
while awaiting confirmatory test results (T4
and TSH), even if the diagnosis of myxedema
coma is only probable.
Hyperthyroidism: It is less common in elderly
than hypothyroidism. Typical eye signs,
tremor, and goiter are less common, but
atypical presentation such as weight loss,
depression, atrial fibrillation, and congestive
heart failure is frequently observed.
Diabetes mellitus: In the elderly, diabetes
differs from that of young patients. Elderly
people are more glucose intolerant and insulin
resistant than young individuals. Relatively
few present with classical symptoms such as
polyuria and weight loss. Many are diagnosed
as a result of screening procedures for medical
or surgical illness.
Depression, impaired cognitive function,
and lack of recognition of thirst and subsequent
dehydration are important factors to be taken
into account in the management of older diabetic
patients, who may also have impaired physical
function, an increased rate of injurious falls,
and increased prevalence of pressure ulcers,
amputations and tuberculosis. Hyperglycemia
can result in a decreased pain threshold leading
to increased incidence of ischemic coronary
events and urinary incontinence.
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Dietary management plays less of a role
in older diabetic patients but exercise, with a
particular emphasis on balance and stability, is
an important component of the management
and treatment of older diabetic patients.
Treatment decisions are influenced by
age and life expectancy, comorbid conditions
and severity of the vascular complications.
Adherence to dietary therapy, physical
activity, and medication regimens may be
compromised by comorbid conditions and
psychosocial limitations. Drug-induced
hypoglycemia has been the main consideration
and the most serious potential complication.
Optimal glycemic control should be
possible for every patient if treatment is
individualized; however, strict glycemic
control may not be achievable in all patients
or even desirable in many elderly patients.
Musculoskeletal Problems
Musculoskeletal pain (Table 28.14) is a
common cause of disability in the older person.
The cause (or site) of musculoskeletal pain
can usually be determined by careful history
taking and physical examination leading to the
appropriate diagnosis (Table 28.15). Although,
the majority of musculoskeletal pain and
disorders in the elderly are self-limiting and
reversible, it’s important not to overlook ‘red
flags’ for musculoskeletal pain (Table 28.16)
Also, physicians should be cautious not
to over-interpret X-ray or similar imaging
findings (e.g. senile, postmenopausal, or
disuse osteoporosis; solitary bone cysts, etc.)
as they are of normal occurrence in the elderly
age group and might not be the reason for the
pain.
Besides pharmacotherapy, the family
physician must guide regarding physiotherapy,
exercises, correct posture, and style of walking,
shoes, and walking aids.
 Chapter 28: Management of Common Geriatric Problems 277
Table 28.14  Different types of musculoskeletal pain Table 28.15  Common causes of musculoskeletal
pain in the elderly
• Bone pain: Usually deep, penetrating, or dull;
commonly due to injury; important to rule out Disease Major site of pain
fracture or tumor.
Osteoarthritis Knee, hip, neck, back,
• Muscle pain: Often less intense than bone pain;
hands
commonly due to injury, an autoimmune reaction,
infection, or a tumor. The pain can also include Rheumatoid arthritis Hands, feet, knees, wrists
muscle spasms and cramps.
• Tendon and ligament pain: often caused by Osteoporosis Back
injuries, including sprains; pain often becomes
Polymyalgia rheumatic Shoulder, neck, arms
worse when the affected area is stretched or
moved. Soft tissue rheumatism Generalized aches and
• Fibromyalgia: A condition that may cause pain joint stiffness
in the muscles, tendons, or ligaments; usually in
multiple locations and can be difficult to describe; Crystal arthritis Feet, hands
usually accompanied by other symptoms such (gout, pseudo gout)
as fatigue, irritability, insomnia, headache, Lumbar/cervical Leg or arm claudicate
depression, anxiety, etc. canal stenosis pain
• Joint pain: Joint injuries and diseases usually
produce a stiff, aching, “arthritic” pain; pain may Bone pain due to Spine or site of pain
range from mild to severe and worsens when malignancy
moving the joint. The joints may also swell. Joint
inflammation (arthritis) is a common cause of pain.
• “ T u n n e l ” s y n d r o m e s : T h e s e i n c l u d e
musculoskeletal disorders that cause pain Table 28.16  Red flags for musculoskeletal pain
due to nerve compression, e.g. carpal tunnel
• Night pain
syndrome, cubital tunnel syndrome, and tarsal
• Fever
tunnel syndrome. The pain tends to spread along
• Sweats
the path supplied by the nerve and may feel like
• Neurological features
burning. These disorders are often caused by
• Previous h/o malignancy
overuse.

Falls and Balance Problems
Falls* and unsteadiness are common in
older people. About one-third of people over
65 years fall each year, and the frequency
increases markedly with advancing age.
Furthermore, the fear of falling may lead
some elders to restrict their activities, which
may lead to a form of “postfall syndrome”25,
in which the patient becomes morbidly afraid
of falls, progressively more immobile, and
socially isolated.
The incidence of falling in elderly is related
to the accumulated efforts of multiple factors**
superimposed in age related changes. These
multiple disorders or risk factors can be directly
grouped into intrinsic and extrinsic factors.26
Intrinsic factors (Table 28.17) are inherent
to the individual and include the presence
of chronic, age-related physical and mental
changes, acute health problems or acute
exacerbations of disease and effects of drugs.
Although some of these may not be treatable,
the family physician should always endeavor to
correct or try to ameliorate as many conditions
as possible, thus decreasing the risk of fall
significantly.
Extrinsic factors (Table 28.18) include
environmental hazards as well as activity

*‘Fall’ can be defined as, “an involuntary event producing a change in posture resulting in the individual
adopting an unpleasant supine position”. This definition differentiates another term ‘trip’, which refers to
an event where some corrective manoeuvres result in maintenance of an erect posture.
**Ref. Chapter 27, Table 27.15.

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 278  Section 6: Geriatric Health
Table 28.17  Intrinsic medical causes of falls
• Cardiovascular:
–– Hypotension (e.g. postural, exertional, drug-
induced)
–– Syncope (e.g. cough/micturition/defecation,
carotid sinus sensitivity)
–– Cardiac arrhythmia (e.g. tachy/
bradyarrhythmia, sick sinus syndrome)
–– Shock (e.g. volume depletion, myocardial
infraction, congestive heart failure, pulmonary
embolism, sepsis)
• Drugs:
–– Antihypertensives, antiarrhythmics, sedatives,
neuroleptics, anticonvulsants
• Endocrine/metabolic:
–– Hypoglycemia, hyperglycemia
• Hematologic
–– Anemia, malignancies
• Neuromuscular:
–– Senile gait disorder
–– Transient ischemic attacks
–– Seizures
–– Parkinson’s disease
–– Dementia
–– Autonomic neuropathy or myelopathy
–– Visual field defects
–– Ménière’s disease
–– Intermittent delirium (e.g. alcohol, drugs)
related factors, such as rising from the chair
or walking. Since most falls occur in or around
the home, it will not be out of place for the
family physician to personally visit the home
of the elderly or depute a visiting nurse or
physical therapist for an in-home evaluation of
potential health hazards and offer suggestions
such as adequacy of lightning (illumination)
in living rooms, bed room, stairs, kitchen,
bathroom and toilet; non-skid floor; furniture
with proper high, arm rest and back support;
toilet seat with proper height; grab bars for
tub; footwear with nonskid soles. Walking aids
and other mobile accessories needed must be
provided on individual basis.*
History alone, especially ‘pre’ fall condition
of the patient, is the most vital part in the
**Ref. Chapter 27: Table 27.13
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Table 28.18 Extrinsic risk factors or environmental
home hazards
• Ground surface:
–– Slippery floors
–– Loose carpets
–– Low-lying objects on the floor, e.g. cords
and wires
–– Stairs with rags or in poor repair
• Furniture:
–– Clutter
–– Unstable or low-lying furniture
–– Low chairs without armrest support or seat
back
–– Beds/cabinets that are too high or too low
• Lighting:
–– Absence of night lights
–– Glare from unshielded windows or lamps or
highly polished floors
• Bathroom:
–– Low toilet seats and/or no secure grab bars
–– Absence of nonslip surfaces
• Others:
–– Poorly maintained walking aids and
equipment
–– Improper shoes (not slip-resistant, high-
heeled, too large)
Ref. Capezuti Elizabeth. Falls. In: Geriatric Secrets.
Forciea MA, et al (Eds). editors. Jaypee Brothers Med.
Publishers, 1st edn. 1996.p.112.
assessment of a person who has sustained a
fall. It is, therefore, strongly recommended
that all elderly patients be asked about falls
or fear of falling and that they undergo a
screening test of gait and balance such as
‘get-up-and-go’** test. A more comprehensive
multifactorial assessment (e.g. medical
assessment, monitoring of drugs, assessment
of physical activity and exercise, home safety
checks and advice, behavior assessment and
its modification) is indicated in elderly who
have difficulties with balance and gait, or who
report recurrent falls.
Visual Impairment
Cataract and glaucoma (symptoms of low
vision, loss of peripheral vision, glare from
 Chapter 28: Management of Common Geriatric Problems 279
lights at night, etc.) and age related macular
degeneration (loss of central vision) are
common in the elderly and need to be evaluated.
Systemic side-effects of eye drops, e.g. beta-
blocker timolol used to reduce intraocular
tension, causing confusion, fatigue, and
asthma should be looked into the elderly.
Sudden, permanent loss of vision in one eye
should alert the physician of the possibility of
giant cell arteritis requiring urgent ophthalmic
referral.
Patients belonging to the high-risk group,
e.g. diabetics, hypertension, family history of
glaucoma, must be regularity referred to an
ophthalmologist for evaluation.
Hearing Problems
The external ears must be examined for
occlusion by cerumen, which can be readily
treated by the family physician by careful
syringing or instrumental manipulation.
Middle ear diseases like acute or chronic
ottitis media need specialist treatment so
as to prevent tympanic perforation and its
intra cranial complications like extradural or
subdural abscess and meningitis.
Hearing loss related to aging, known
as presbycusis, affects significant elderly
population. In such individuals, a hearing aid
may be useful.
All cases of unilateral hearing loss with
tinnitus or imbalance must be carefully
evaluated to rule out acoustic neuroma.
Nutrition
Older persons are particularly vulnerable
to malnutrition. The reasons older people
may eat too little food can be due to poverty;
disabilities or functional impairments resulting
in their inability to shop for groceries or cook
for themselves; co-morbid chronic diseases
and conditions, many of which are associated
with malnutrition; too many medications;
loss of their natural teeth contributing to
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problems with chewing and swallowing and
too dependent on others.
Degenerative diseases such as cardio­
vascular and cerebrovascular disease,
diabetes, osteoporosis and cancer, which are
among the most common diseases affecting
older persons, are all diet-affected.
Micronutrient deficiencies are often
common in elderly people due to a number of
factors such as their reduced food intake and
a lack of variety in the foods they eat.
In the elderly, both lean body mass and
basal metabolic rate decline, therefore, their
energy requirement per kilogram of body
weight is also reduced. Therefore, guidance
must be given in dietary requirements of
normal elderly persons and also for those
requiring special dietary considerations e.g.
elderly with diabetes, cardiac, renal and other
diseases along with poor dentition, that reduce
the patient’s nutritional status.
In general, to meet the nutritional needs
of the elderly it is essential to provide a
balanced diet containing carbohydrates (65%),
fats (about 25%) and proteins (about 10%),
which include adequate doses of vitamins,
minerals, antioxidants and fiber. If the family
physician detects any sign of nutritional
deficiency—e.g. protein, calorie malnutrition,
anemia, avitaminosis, etc. the diet must be
modified. Increasing consumption of fruit and
vegetables by one to two servings daily could
cut cardiovascular risk significantly.
Although weight loss is seen with aging,
recent unintentional weight loss – especially if
it is more than 10% of one’s usual weight over a
period of 6 months or a loss of 5% in one month
must alert the physician to find the underlying
pathology. The leading causes of involuntary
weight loss are depression (especially in
residents of long-term care facilities), cancer
(lung and gastrointestinal malignancies),
cardiac disorders and benign gastrointestinal
diseases.
 280  Section 6: Geriatric Health
Exercises*
Research shows that it’s never too late to adopt
and reap the health benefits from a more
active lifestyle. For example, older adults who
are active will reduce their risk of coronary
heart disease and stroke, type 2 diabetes,
colon cancer, breast cancer, osteoarthritis, hip
fracture, falls, depression and dementia.
Before initiating an exercise program, older
adults should undergo a history and physical
examination directed at identifying cardiac
risk factors, exertional signs/symptoms, and
physical limitations.
The difference in the exercise prescription
for the elderly participant is the manner in
which it is applied. Given that the elderly
person is more fragile and has more physical-
medical limitations than the middle-aged
participant, the intensity of the program is
usually lower while the training frequency
and duration are increased. The mode of
training should avoid high-impact activities,
and the progression of training should be
more gradual. The prescribed training heart
rate for the elderly at 40–80% of maximal heart
rate reserve is slightly lower than the 50–85%
recommended for young and middle-aged
participants.27
There are few contraindications to aerobic
exercise or resistance training (e.g. severe
orthopedic conditions, uncontrolled diabetes
and hypertension, etc.). Even patients with
these conditions can safely exercise at low
levels once appropriate evaluation and
treatment have been initiated.
Family physician should enthusiastically
discuss physical activity at every office visit,
including any symptoms associated with
exercise, know who needs further evaluation
before initiating an exercise program, explore
with patients which types of exercise would
*Website for exercises for older people-http://www.nhs.uk/Tools/Documents/NHS_Exercises For Older
People.pdf
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best fit into their routines and what support is
needed to overcome their sedentary lifestyles
and encourage continued participation.
Generally, the exercise prescription for the
elderly should emphasize low to moderate
intensity and low-impact activities, avoid
heavy static-dynamic lifting, and allow a
gradual progression in training. The increased
vitality, strength, flexibility, balance, and
general sense of well-being that can be
achieved through this intervention will reward
patient and physician alike.28
Attitudes for a Successful Geriatric
Practice29
™™ Consider broad-based rather than narrowly
focused interventions
™™ Appreciate the importance of the social
factors in older people’s health and well
being
™™ Maintain an active approach in the face of
degenerative or terminal disease
™™ Practice patience for the time required and
complexity encountered with seniors
™™ Anticipate being confronted with one’s
youth and inexperience
™™ Encourage team work with family and
other providers (shared authority)
™™ Focus on function, rehabilitation, and
quality of life rather than survival
™™ Strive to anticipate the older adult’s needs
and advocate for care
™™ Approach the elderly with a “sort out”
rather than a “rule out” view of illness and
disability causality
™™ Cultivate an appreciation for cultural as
well as physiologic diversity
™™ Be aware of greater heterogeneity among
the aged; have flexibility
 Chapter 28: Management of Common Geriatric Problems 281
™™ Be willing to physically interact (touch);
give concrete health advice
™™ Have capacity to tolerate dependency yet
press for optimum autonomy
™™ Be able to lead as well as follow in the
person’s care and decisions
™™ Display an ongoing commitment to clinical
education.
Conclusion
The role of the family physicians is very
specific and important. They have to be
vigilant to detect the onset of any disease or
disability at the earliest and treat accordingly.
A generous dose of psychological support and
paramedical advice has to be given.
Treatment requires a multifaceted and
comprehensive approach. Geriatric treatment
emphasizes on reducing symptoms and
improving functions rather than curing the
underlying pathology, which is not always
possible.
Family physicians help the elderly to realize
that they have to learn to live with disability.
Rehabilitation has to be carefully planned and
implemented with the help of paramedical
staff. Even a partial improvement by way
of reduction of pain and increased activity
means a lot between a life of abject misery with
dependence on others and a tolerably happy
independent existence.
References
1. Aggrawal A, et al. The International Year of
the Older Persons. J Ind Med Assoc, 1999;
97(4):117–18.
2. World Health Organization. Towards age-
friendly primary health care (Active ageing
series), 2004.
3. Michel JP, et al. Europe-wide survey of
teaching in geriatric medicine. J Am Geriatr
Soc. 2008;56(8):1536–42. doi: 10.1111/j.1532-
5415.2008.01788.x.[PMID:18808600 : Abstract].
4. Reuben DB et al. How many physicians will
be needed to provide medical care for older
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persons? Physician manpower needs for the 21st
Century. J Am Geriatr Soc, 1993;41:444–53.
5. Houde SC, et al. Caring for an aging population:
review of policy initiatives. J Gerontol Nurs,
2009;35(12):8–13. doi: 10.3928/00989134-
20091103-04. Epub 2009 Dec 11. [PMID:
1992871: Abstract]
6. Kovner CT, et al. Who cares for older adults?
Workforce implications of an aging society.
Health Aff (Millwood), 2002;21(5):78–89.
[PMID: 12224911:Abstract].
7. Xakellis GC. Who provides care to Medicare
beneficiaries and what settings do they use? J
Am Board Fam Pract, 2004;17(5):384–7. [PMID:
15355953: Free Article].
8. Ingle Gopal K, et al. Geriatric health in
India: Concerns and solutions, 2008;33(Issue
Number:4):214–8.
9. Li I, et al. A national survey on the current
status of family practice residency education in
geriatric medicine. Fam Med, 2003;35(1):35–41.
10. Gazewood JD et al. Geriatrics in family practice
residency education: an unmet challenge. Fam
Med, 2003;35(1):30–4.
11. R o t h m a n A A , e t a l . C h ro n i c i l l n e s s
management: what is the role of primary care?
Ann Intern Med, 2003;138(3):256–61. [PMID:
12558376: Abstract].
12. Moore A, et al. Interprofessional and integrated
care of the elderly in a family health team. Can
Fam Physician, 2012;58(8):e436–41. [PMID:
22893345. Free PMC Article].
13. Park M, et al. Geriatric depression in primary
care. Psychiatr Clin North Am, 2011;34(2):469–
87, ix-x. doi: 10.1016/j.psc.2011.02.009. [PMID:
21536169:Free PMC Article].
14. Abraham VJ, et al, Suicide in the elderly
in Kaniyambadi block, Tamil Nadu, South
India. Int J Geriat Psychiatry, 2005;20:953–5.
doi: 10.1002/gps.1385.
15. Arroll B, et al. Screening for depression
in primary care with two verbally asked
questions: cross sectional study. BMJ, 2003;327
(7424):1144–6.[PMID: 14615341: Abstract].
16. Johnston CB, et al. Geriatric Disorders. In:
McPhee SJ, et al (Eds). Current Med. Diag. and
Treat. McGraw-Hill, 48th edn. 2009;63.
 282  Section 6: Geriatric Health
17. Web site: http://www.ncea.aoa.gov/ncearoot/
Main_Site/FAQ/Questions.aspx
18. Fisher BS, et al. The extent and frequency of
abuse in the lives of older women and their
relationship with health outcomes. Gerontologist.
2006;46(2):200–9.[PMID: 16581884:Abstract].
19. A. Etemadi A, et al. Psychological Disorders
of Elderly Home Residents. Journal of Applied
Sciences: 2009;9(Issue: 3):549–54.
20. Johnston CB, et al. Geriatric Disorders. In:
McPhee SJ, et al. Current Med. Diag. and Treat.
McGraw-Hill, 48th edn.2009:71.
21. Web site: http://www.galter.northwestern.
edu/geriatrics/chapters/cardiovascular_
function_disease.cfm
22. Jomarie Zeleznik. Clinics in geriatric medicine.
In: Normative aging of the respiratory system.
2003;19(Issue 1):1–18.
23. Fastbom J, et al. Levels of serum creatinine and
estimated creatinine clearance over the age of
75: a study of an elderly Swedish population.
Arch Gerontol Geriatr, 1996;23(2):179–88.
[PMID:15374161:Abstract].
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24. MacAulay J, et al. Serum creatinine in patients
with advanced liver disease is of limited
value for identification of moderate renal
dysfunction: are the equations for estimating
renal function better? Can J Gastroenterol,
2006;20(8):521–6. [PMID: 16955148: Free PMC
Article].
25. Evans JG. Medicine in old age. In: Warrell DA et
al (Eds). Oxford TB of Medicine, 4th edn. Vol.
III: 1381.
26. Neil M, et al. Geriatric Medicine. In: Kasper
DL, et al. Harrison’s Prin. Of Int Med Vol. 1;
16th edn. 2005;50–51.McGraw-Hill
27. Pollock ML, et al. Exercise training and
prescription for the elderly. South Med J. 1994;
87(5):S88–95. [PMID: 8178210: Abstract].
28. Heath JM, et al. Prescribing exercise for frail
elders. JABFP. 2002;15(3).
29. Geriatrics-Myths and Perspectives, Special
Guest Editorial. February 2003:
Web site: http://www.medscape.com/
viewarticle/449250_print
 29 PRACTICAL PRESCRIBING
TO THE ELDERLY

“If what you are doing is doing good, keep doing it. If what you are doing is not doing good, stop doing it.
If you don’t know what to do, do nothing. Never make treatment worse than the disease.”

Concerns over Aging Population
One of the most important demographic trends
facing the world at large is the aging of its
population. In almost every country, as a result
of longer life expectancy and declining fertility
rates, the proportion of people over 60 years of
age is growing faster than any other age group.
All over the world, between 2000 and 2050, the
absolute number of people aged 60 years and
over is expected to increase from 605 million to
2 billion. By 2050, India will be home to one out
of every six of the world’s older persons.*
Modern medications, improved standards
of nutrition, and good hygiene practices have
contributed significantly to increased longevity,
improved health, and enhanced quality of life
for older people. Today’s medicines effectively
treat diseases that were untreatable just a few
years ago, relieving pain and suffering and
preventing life-threatening complications of
many diseases and conditions common in the
older population.
This brings great challenges to family
physicians. The demand for medical attention
in the later stage of life is likely to increase
substantially in future. A majority of the health
workers in the most healthcare settings will
deal with substantial numbers of older adults
whether or not they are specialists.
This phenomenon has also contributed to
the increase in the prevalence of chronic disease.
With people living longer, many diseases and
conditions, such as arthritis, cardiovascular
ailments, and neurodegenerative diseases,
including Alzheimer disease, have time to
manifest. Long-term care services, such as
nursing homes, home health, personal care,
day care and hospice care will become much
more important sources of care. Since this is
an inevitable phenomenon in a rapidly aging
population, the healthcare costs have increased
due to aging. Therefore, physicians must develop
appropriate medication management strategies
to reduce their cost. It is also prudent to take
into consideration the altered drug kinetics
and responses as well as altered sensitivity to
drugs, impaired compensatory, mechanisms,
unusual disease presentation, as well as the
physiological changes that occur with aging**
while administrating medications to the
elderly. These biological, pharmacokinetic and
pharmacodynamic changes in the elderly

*The share of India’s population ages 60 years and older is projected to climb from 8 percent in 2010 to 19
percent in 2050, according to the United Nations Population Division (UN 2011). By mid-century, India’s
60 and older population is expected to encompass 323 million people.
**For example, decreased cardiac output, vital capacity and creatinine clearance; lean body mass declines
and arteriosclerosis, atrophic gastritis, altered hepatic drug metabolism and osteoporosis develops.

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 284  Section 6: Geriatric Health
apprise the physician to judiciously balance
medications for complex comorbid chronic
diseases (Table 29.1), minimize polypharmacy,
and remain vigilant to potential medication
misuse.
Prescribing Cascade
Age is clearly associated with both acute and
multiple chronic conditions, e.g. hypertension,
acute coronary syndromes, stroke, diabetes
mellitus, obstructive lung diseases, Parkinson’s
disease, arthritis, osteoporosis, malignancy,
and the treatment of these illnesses are likely
to be associated with the use of multiple
drugs. However, for elderly, medications—
both prescription and over-the-counter (non-
prescription)—can be a two-edged sword. When
not used appropriately, effectively, and safely,
this ‘inappropriate prescription’ (IP)* and lack
of monitoring of multiple drugs increases the
likelihood of unwanted drug reactions.
Prescription of potentially IP to older
people is highly prevalent and serious global
healthcare problem in elderly people, leading
to increased risk of adverse drug reactions
(ADRs)**—polypharmacy*** being the main
risk factor for both IP and ADRs.
The use of multiple medications in the
older population may be partly due to what
has been called the “prescribing cascade” (Fig.
29.1). A new medication added to an elder’s
regimen may cause an adverse event that is then
misinterpreted as a new medical problem. This
starts a vicious circle of testing, more medication,
more drug/drug reactions, and more adverse
Table 29.1  Characteristics of chronic diseases
• Have a complex and multiple causes
• Generally have a gradual onset, although sudden
onset of a chronic illness may occur
• Manifests in early life and gradually worsens
over years
• Quality of life deteriorates over a period of time
due to disability and functional limitations
• May not be life-threatening to begin, but over
the years they aggravate mortality, leading to
premature death
Fig. 29.1  Prescribing cascade
events which is misinterpreted as a new medical
condition. This new medical condition is then
treated with another medication that may itself
cause adverse effects. New adverse effects may
then be treated with additional medications.
For example, consider a 75-year-old woman
with hypertension taking amlodipine 10 mg
a day (drug 1). She complains of palpitation
and pedal edema, which are common ADRs
of amlodipine. However, to “treat” the ADRs
of this medication, a prescriber may initiate a
beta-blocker and a diuretic (drug 2). Here, the
prescribing of one therapy to treat hypertension

*Prescribing may be regarded as inappropriate when alternative therapy that is either more effective or
associated with a lower risk exists to treat the same condition.
**The WHO defines an ADR as “any response to a drug which is noxious and unintended, and which occurs
at doses normally used in man for prophylaxis, diagnosis or therapy of disease, or for the modification of
physiological function”. If the response to a usual dose is excessive, it is termed idiosyncratic. If the observed
signs and symptoms are an unexpected response of the immune system, the response is termed hypersensitivity.
***At one time polypharmacy was defined only as multiple drug use, but this definition is not specific
enough. Polypharmacy is now used to indicate that a particular patient receives too many drugs, drugs
for too long a time, or drugs in exceedingly high doses.

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 Chapter 29: Practical Prescribing to the Elderly 285
has resulted in addition of two drugs, i.e. a beta-
blocker and a diuretic. After a period of therapy,
this woman complains of syncopal attacks and
severe leg cramps, and a routine ECG shows
signs of bundle-branch block and hypokalemia,
i.e. cumulative ADRs.
The key to avoiding the prescribing cascade
is to determine whether the initial medication is
actually needed. If not, it should be discontinued
immediately. If the medication is necessary
but is causing problems, then a lower dose
of the medication or a more appropriate
medication with potentially fewer adverse
effects should be prescribed. Fortunately, today
many treatment options are available for a wide
range of conditions and symptoms. Patients
and caregivers must understand that they have
options; if a medication either is not effective or is
causing undesirable side effects, there are usually
other medications that can be prescribed instead.
It is also essential for the physician to pay
due attention to some of the non-specific
abnormalities in the elderly which do not need
active treatment (Table 29.2).
Polypharmacy
Several factors contribute to polypharmacy
among elderly patients:
™™ Physicians may be prescribing more drugs
for their elderly patients than they have in
Table 29.2  Commonly present non-specific
abnormalities in elderly
• Diminished skin turgor
• Senile purpura and hirsutism
• Wasting of muscles of hand
• Ventricular premature beats
• Systolic murmurs—mostly benign aortic stenosis
• Rales at the base of lungs due to fibrotic changes
in lung
• Osteoporosis leading to vertebral compression
fracture
• Impaired GTT
• Testicular atrophy
• Diminished vibratory sensation in toes
• Diminished or absent ankle jerks
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the past simply because there are more
drugs available for treating these patients.
Although the discovery of a broad range
of pharmaceuticals for a wide variety of
conditions has helped many patients, this
new development, unfortunately has also
led to both overuse and inappropriate use
of prescription medications.
™™ Many drugs that were once obtainable only
with a prescription, such as omeprazole and
loratadine, are now readily available over
the counter, and their use is on the rise.
™™ In addition, complementary and alternative
medicines, such as herbal therapies, are
becoming increasingly popular among all
patients, including the elderly.
™™ Compared to the general population,
elderly are more likely to have several
chronic disorders, each requiring at least
one medication.
™™ Age-related decrease in organ function
reserve and homeostatic mechanisms
(e.g. decrease in glomerular filtration
rate, reduced hepatic clearance, reduced
protein-binding of some drugs) combine
with chronic illnesses make elderly patients
much more vulnerable to ADRs.
™™ Elderly patients with more than one health
condition are likely to receive care from
several healthcare providers, each of whom
may prescribe a different medication to
treat the same symptoms.11
™™ As explained above, the possibility of
unsuspecting phenomenon of ‘prescribing
cascade’ adds to polypharmacy.
In addition to the health risks of
polypharmacy, patients who are taking
multiple medications face tremendous
economic costs. It’s not uncommon for our
patients stating that they cannot afford all
their prescribed medications and ask which
ones are the most important. In addition to the
economic costs of polypharmacy is the toll of
drug-drug and drug-disease interactions.
 286  Section 6: Geriatric Health
It is relatively straightforward to know
when to start a drug based on an indication,
but deciding when to stop it can be a
challenge. It is an even greater challenge in
our fragmented healthcare system where other
healthcare practitioners, such as hospitalists or
specialists may have started a medication. This
fragmentation sometimes leaves the physician
guessing why the medication was started and
whether it can be stopped.
The fact that a patient is on multiple
medications to treat multiple disease states is
not independently problematic. For example,
consider a patient with type 2 diabetes and
existing coronary artery disease who has
undergone angioplasty after a myocardial
infarction. It is not unreasonable or uncommon
for this patient to be on multiple medications
to reduce the long-term risk for diabetes
complications and secondary coronary events.
In fact, as per the recommended treatment
guidelines , this patient will receive minimum
of six concurrent prescription therapies
– either independently or in combined
formulations - consisting of insulin, oral anti-
diabetic/hypoglycemic agents, anti-anginal
drugs, statins, fibrates, and anti-platelet drugs.
Polypharmacy becomes problematic when
negative outcomes occur due to unnecessary
and/or inappropriate medication prescribing,
leading to increased risk for drug interactions
and ADRs, medication nonadherence, and
also increased overall drug expenditures.
When should an Adr be Suspected?
Multiple factors independently predict an
increased risk for ADRs in older patients (Table
29.3).
Many ADRs are common and well
understood, e.g. bleeding complications
or dyspepsia or gastritis associated with
*Any symptom in an elderly patient should be considered a drug side effect until proved otherwise. Brown
University Long-term Care Quality Letter, 1995.
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Table 29.3  Patient characteristics predictive of higher
risk of ADRs
• No. of drugs
–– 8 drugs = high risk
–– ≥ 5-7 drugs = intermediate risk
• Previous ADR
• ≥ 4 medical comorbidities
• Liver disease
• Heart failure
• Renal disease
• Receiving high-risk drugs:
–– Anticoagulants
–– Insulin or oral hypoglycemic drugs
–– Psychotropic medications
–– Sedatives/hypnotics
–– Cardiovascular drugs (especially digoxin,
nitrates, and vasodilators)
–– Nonsteroidal anti-inflammatory drugs
• Cognitive impairment
• Living alone
• History of nonadherence
• Known psychologic disorders or substance
abuse
Sources: 1. Bayoumi I, et al. Interventions to improve medication
reconciliation in primary care. Ann Pharmacother. 2009;
43:1667-1675.
2. Klarin I, et al. J. The association of inappropriate druguse
with hospitalisation and mortality: a population-based study of
the very old.JAMA. 2005; 293:2131-2140.
3. Scott IA, et al. Minimizing inappropriate medications in older
populations: a 10-step conceptual framework. Am J Med. 2012
Jun; 125(6):529-37.e4. doi: 10.1016/j.amjmed.2011.09.021.
Epub 2012 Mar 3. Review. [PMID: 22385783].
anti-coagulants, aspirin, and NSAIDs ;
hepatotoxicity with antitubercular drugs;
cough with ACE-inhibitors; bronchospasm
with beta-blockers ; and bone-marrow
depression with chemotherapeutic agents.
However, any time an elderly patient has an
unexpected change in physical, cognitive, and
physical function, or virtually any domain of
function, an ADR should be considered and
should prompt an early evaluation of drug
therapy and work-up for its potential etiology
(Table 29.4). Therefore, the possibility of an
ADR needs to be included in every differential
diagnosis considered for an elderly patient.*
Other factors which are useful pointers to
 Chapter 29: Practical Prescribing to the Elderly 287
Table 29.4 Signals that may point to a medication Principles of Good Prescribing
problem
The basic aim while treating elderly people in
Musculoskeletal: an office setup is to ameliorate the patients’
• Falls
Neuropsychiatric: symptoms, so that they can get back to normal
• Restlessness pre-sickness, independent life activities.
• Confusion Hence, although multiple illnesses are the
• Loss of memory
• Sleep disorders rule, and chronicity of the problems frequent,
• Dizziness prescribing for the elderly by following
• Depression principles of good prescribing reduces the risk
Gastrointestinal:
• Weight loss
of drug toxicity (Table 29.5).
• Constipation Further, blanket application of evidence-
• Bowel changes based clinical practice guidelines must be
Renal: approached with caution in the elderly. Most
• Incontinence
guidelines are based on a single disease focus,
but most elderly patients have comorbidities.
ADRs in elderly include: This makes the risks of drug-to-drug
™™ Taking five or more prescribed medications* interactions more likely.
At the same time, older people are often
™™ Taking dietary supplements, vitamins or
denied potentially beneficial, clinically
over-the-counter drugs
indicated medications without a valid reason.
™™ Taking homeopathic remedies or herbal
For these reasons, new geriatric IP criteria have
medicines
been devised and validated, called ‘screening
™™ Multiple pharmacies to fill prescriptions
tool of older persons’ prescriptions’ (STOPP)
™™ Multiple prescribers; having more than one
and ‘screening tool to alert to right treatment’
doctor prescribing medications
(START) for detection of potential errors of
™™ Multiple dosing schedule
prescribing commission and omission (Ref.
™™ Poor dexterity; having trouble opening
Box 29.1) .
medicine bottles, inability to break tablets
™™ Having poor eyesight; difficulty reading
labels on prescription labels and over-the- Non-drug Therapy
counter products Basically, drugs are not the answer to all patients’
™™ Difficulty hearing instructions from problems. Often social stress rather than physical
healthcare professionals illness is the main problem, and hence social
™™ Impaired communication problems manipulation, e.g. minimizing social isolation
™™ Impaired cognitive status; poor recall, rather than drug therapy might provide greater
forget to take medications relief, especially for the elderly. Sometimes
™™ Recent discharge from hospital patient’s concern about symptoms is mistaken
™™ Use of drugs with a narrow therapeutic as a desire for a medication when in reality the
index, e.g. digoxin, warfarin, phenytoin, concern is for reassurance. Further, if it is possible
etc. to treat a condition or a symptom with a local or
™™ Living alone. physical measure, this is always preferable to

*The frequency of an ADR is estimated to be 6% when two drugs are taken, 50% when five drugs are
taken, and almost 100% when eight or more drugs are taken. (Ref. web site: http://www.medscape.com/
viewarticle/461905_print).

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 288  Section 6: Geriatric Health
Table 29.5  Principles of good prescribing to the
elderly
• Check
–– Is the diagnosis correct?
–– Is treatment necessary?
–– Is this the safest drug available?
–– Is it effective?
–– Is it acceptable to patient?
–– Is there duplication with other drugs being
used?
• Choice of drug
–– Is this evidence-based practice? Is there
relevant evidence of effectiveness?
–– Short-rather than long-acting
–– Distinctive color and shape
–– Simple dosage regime
• Dosage
–– Is this the most appropriate dose, route of
administration and dosage form?
–– Any dose adjustment needed for renal and
other problems?
–– Titrate drug dosage based on patient’s
response
–– If in doubt, ‘start low, go slow’
• Monitoring
–– For how long is the medication required?
–– Do the benefits outweigh the risks?
–– What ADRs should be watched for?
–– Is the indication for treatment still present?
–– When should dosage be reviewed?
–– When can the drug be stopped?
–– Do not treat the ADR of a medicine by adding
another medicine
–– Educate about the importance and use of
each medicine
–– Remember iatrogenesis.
the use of systemic medication. Physiotherapy,
massage, walking aids is preferable to NSAIDs
for musculoskeletal problems. Raising the head
of the bed, advising against too many large
meals, alcohol, smoking is preferable to systemic
medications for GORD. The role of physical
exercise, lifestyle changes, and holistic living
have been the cornerstone in the management
of coronary artery diseases, cerebrovascular
accidents, diabetes, psychosomatic disorders,
obesity, hypertension and other innumerable
disorders. Evidence supports the conclusion that
even the oldest old can benefit from beginning
an exercise program.
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Box 29.1: Stopp/Start Screening Tool
Potentially inappropriate prescribing (IP) is an
issue of major importance in the pharmacotherapy
of older people globally. To date, Beers’ criteria
have been in common research usage for defining
potentially inappropriate medications (PIMs)
in older people. However, Beers’ criteria have
a number of serious flaws and are of doubtful
relevance to routine geriatric pharmacotherapy.
Prospective data show that STOPP criteria detect
adverse drug effects (ADEs) that are causal or
contributory to acute hospitalization in older people
2.8 times more frequently than Beers’ criteria. This
suggests that ADEs are likely associated with PIMs
in older people, contrary to recent research data
showing no significant association on the basis of
defining PIMs using Beers’ criteria.
Recent studies show that STOPP/START criteria
as an intervention significantly improves medication
appropriateness in hospitalized older people.
Whether STOPP/START can prevent ADEs and
reduce drug costs remains to be elucidated by
means of further randomised controlled trials.
However, STOPP/START is a valid, reliable
and comprehensive screening tool that enables
the prescribing physician to appraise an older
patient's prescription drugs in the context of his/
her concurrent diagnoses.
Source: http://www.ncbi.nlm.nih.gov/pubmed/ 18218287
Abbreviation: STOPP, Screening Tool of Older Person’s
Prescriptions; START, Screening Tool to Alert Doctors
to Right Treatment
Begin Therapy with Clear Endpoints
in Mind
Every time elderly patients receive a medication,
its outcome may be beneficial or harmful to
them. Although some medications neither
benefit nor do any harm to elderly patients, e.g.
placebo medications, it is critical to have advance
knowledge and prepare oneself to evaluate these
outcomes prior to starting the drug. Physicians
must know the baseline or initial parameters of
the ‘target symptom’ they are evaluating a drug
for its final outcome. For example, if a drug is
expected to produce orthostatic hypotension
 Chapter 29: Practical Prescribing to the Elderly 289
as an adverse consequence, the physician must
know the initial blood pressure values in sitting,
standing, lying positions. Similarly, the advance
knowledge of symptom such as constipation or
an ECG finding of bundle-branch block cautions
the physician to avoid prescribing drugs like
tricyclic antidepressants or beta-blockers which
are known to aggravate constipation or cause
syncopal attacks respectively.
Treat the Disease Process Rather
than Symptoms
Try to establish a working diagnosis or a
definite diagnosis first, i.e. know what you are
treating. Establishing a diagnosis often permits
selection of the proper drug or drugs and a
treatment period. The therapeutic goal must be
to modify the natural disease process (diabetes,
hypertension, coronary syndromes, rheumatoid
arthritis, and depression) and to enhance
functional ability and life expectancy that results
in improved quality of life. It is also important to
consider whether any new symptoms and signs
could come from drugs the patient is already on,
so as to avoid a prescribing cascade.
Start Low Go Slow
Unless a condition needs to be treated
immediately, therapy is begun with less than
the usual adult dosage and the dosage increased
slowly, consistent with its pharmacokinetics in
older patients. As a rule, one-quarter to one-half,
the usual starting dose of a drug is safe. However,
age-related changes in drug distribution and
elimination are variable among individuals, and
individual titration will be required. It is also wise
to be cautious about adding a new medication
without eliciting the history of drug allergy and
optimizing current drug regimen.
Medication Debridement—
Re­ducing Medications and Doses
When you decide to treat a patient, especially
an elderly, it’s helpful to ask the following series
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of questions (Table 29.6) and use the answers
to help guide your decisions about starting,
stopping, or continuing medications, particularly
in patients in the geriatric population.
Unnecessary drugs accumulate, which
the patient may be consuming. Such drugs
need to be identified and discontinued.
This process must be slow and done in
small increments. Follow-up is essential
so as to watch for rebound phenomenon
often observed after stopping a particular
drug, e.g. antidepressants, antiepileptics,
antihypertensives, and corticosteroids.
Review the Drug Profile at Every
Visit
Drugs are more often part of the problem than
part of the solution. Every patient’s visit must be
an occasion for a drug review. This makes the
process of periodically reducing unnecessary
drugs easier and helps to prevent accumulation
of toxic unnecessary forgotten medicine. The
importance of this is stressed in many policy
documents and guidelines on a common set of
definitions and principles for medication review
have been issued (Table 29.7).
Table 29.6  Medical debridement—the 10 questions
to ask
  1.  Do I know the medication?
  2.  Is the drug indicated?
  3.  Has the drug outlived its utility?
  4. Do side effects outlive the potential benefits of
this drug?
  5. Do this drug interact with another drug or one of
the patient’s diseases?
 6. D o this drug interact with herbal or OTC
medications?
  7. Is this drug being used to treat the side effects
of another drug?
 8. Is there a non-pharmacological approach
available instead of a drug?
  9. Will the patient live long enough to gain potential
benefit from the medication?
10.  Is this drug harmful?
 290  Section 6: Geriatric Health
Table 29.7  Levels of medication review
The levels of review in the existing framework are:
Level 1: Prescription review: Technical review of the
list of patient’s medicines, usually conducted without
access to the clinical notes, and does not usually
include a review of the full repeat prescription. The
patient may be present, but not always.
Level 2: Concordance and compliance review:
Treatment review of medicines with patient’s full
notes; normally occurs under the direction of a
doctor, nurse, or pharmacist, in partnership with the
patient and/or the patient’s carer or advocate.
Level 3: Clinical medication review: Face-to-face
clinical medication review of medicines and condition
requiring access to the patient’s notes, full record of
prescriptions, over-the-counter remedies, and lab
reports. The patient is involved as a full partner in
the discussion.
Effective Communication
Although family physicians are ideally placed to
manage all medications used by their patients,
it is prudent not to assume they are the only
prescriber or that the patient is taking what they
have prescribed. There is evidence that elderly
people visit multiple family physicians and new
medication may be prescribed at discharge from
hospital, outpatient clinics, and emergency
department visits. Sharing such information is
vital. Accurate knowledge can only be acquired
with good patient-doctor communication
and relies heavily on effective communication
between primary and secondary care.
Medication Noncompliance in the
Elderly
Medication non-compliance is defined as a
patient’s passive (i.e. non-intentional) failure
to follow a prescribed drug regimen in the
manner recommended by the doctor.
Non-compliance in the elderly is a
significant problem facing medical practice
today. It has been estimated that as many as
50% of prescriptions for elderly fail to produce
the desired results because of non-compliance.
Additionally, between one third and two thirds
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of all medication-related hospital admissions
are attributed to non-compliance.
The most important factor that leads to
noncompliance in elderly is due to difficulty
faced by elderly in following prescription
instructions because they generally have
more medication prescribed, often suffer from
cognitive decline, and frequently have physical
limitations such as failing eye sight and
hearing that may further impede compliance.
Other important determinants of non-
compliance are:
™™ Demographic factors: such as age, sex,
education level, socioeconomic status,
occupation, marital status
™™ Patient’s attitude: If patient perceives their
illness to be severe then compliance will
be more
™™ Physician-patient relationship: Strong
physician patient relationship leads to
greater compliance
™™ Patient’s knowledge: knowledge about
disease and treatment has beneficial effect
on compliance
™™ Therapeutic regimen: complex medication
regimen will lead to noncompliance.
Adverse effects of drugs also lead to non-
compliance.
Measures to Enhance Compliance
™™ Understand the patient’s drug history in
detail including use of over-the-counter dugs
™™ Give permission for the patient to relate
exactly how drugs are taken
™™ Probe for the patient’s opinion about
problems and adverse effects
™™ Educate the patient on the relative
importance of each medication
™™ Use family, visiting nurses, and home
health aids as allies
™™ Simplify drug regimens and encourage
easy open bottles
™™ Pay attention to cost if this is a concern to
the patient
 Chapter 29: Practical Prescribing to the Elderly 291
™™ The patient should be taught the principles
of self-medication before leaving the
hospital or if is being treated as outpatient.
This is best done predischarge.
Ethical Principles
The family physician, besides knowing the
basic theory and practice of prescribing drugs
to the elderly, should be guided by the ethical
principles that form the basis for appropriate
prescribing in elderly people:
™™ Beneficence—“what is the evidence for the
likely benefit in this particular patient?”
Can the dosage of drugs gradually reduced
or even withdrawn (drug holiday) after a
period of stabilization while monitoring
the patient during this transition?
™™ Nonmaleficence—“what are the adverse
effects likely to be in particular patients,
taking into consideration their age,
comorbidities and other medications?”
The high rate of adverse drug reactions in
elderly patients should be balances against
the often-uncertain efficacy evidence in
older people before drugs are prescribed.
™™ Autonomy—“what does the older person
want?” Older patients may be concerned
about issues of independence and side
effects of medications rather than whether
their disease or risk factor is managed
according to the latest published guidelines.
Other points which physicians should
understand are:
™™ The treatment of a disease should not be
more unpleasant than the disease itself,
i.e. ‘primum non nocere.’
™™ Often, what the patient is craving for is a pair
of sympathetic ears to listen to his woes, and
does not really care for a drug. A prescription
need not be a necessary part of treatment.
™™ There is no drug to combat senescence –
many a pharmaceutical company’s claim
notwithstanding.
™™ Mere prolongation of life can never be a
valid aim.
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Conclusion
Balancing medication use in the elderly is
a complex task, made more difficult by the
physiological changes and increased burden of
disease seen with aging. The success of a drug
therapy in elderly depends on considering
these factors in addition to correct diagnosis,
treatment plan, prescription, patient education
and dose adherence. Care should be taken to
avoid iatrogenic diseases in this population
by avoiding inappropriate prescribing. For
appropriate and rational prescription in
elderly patients the following factors should
be taken into account:
™™ Prescribing in the elderly is made more
complex by the physiological changes
associated with aging and increased
burden of disease.
™™ Polypharmacy is associated with a
significantly increased risk of adverse
drug reactions and represents a largely
preventable cause of patient morbidity.
™™ Underprescribing on the basis of age alone
may result in suboptimal patient care.
™™ Regular review and rationalization of
medications should be part of routine
practice and can improve patient outcomes.
Above all adding quality life to years should
be the major concern of a physician than mere
addition of years to life.
“The challenge for the general practitioner
is to balance an incomplete evidence base
for efficacy in frail, older people against the
problems related to adverse drug reactions
without denying older people potentially
valuable pharmacotherapeutic interventions”.
References
1. Cerreta F, et al. Drug policy for an aging
population--the European Medicines
Agency’s geriatric medicines strategy. N Engl
J Med, 2012;367(21):1972-4. doi: 10.1056/
NEJMp1209034. [PMID: 23171092: Free Article].
2. Web site - http://www.who.int/ageing/en/
 292  Section 6: Geriatric Health
3. Assessing the Costs of Aging and Health
Care. Web site: http://www.nia.nih.gov/
research/publication/global-health-and-
aging/assessing-costs-aging-and-health-care
4. Cameron KA, et al. A Guide to Medication and
Aging. American Society on Aging, Academic
journal article from Generations, Vol. 24, No. 4.
5. Juliv Galivis, et al. Polypharmacy: Keeping
the elderly safe. Web site - http://www.
modernmedicine.com/modern-medicine/
news/polypharmacy-keeping-elderly-safe
6. Guiding principles for the care of older adults
with multimorbidity: an approach for clinicians.
J Am Geriatr Soc. 2012;60(10):E1-E25. doi:
10.1111/j.1532-5415.2012.04188.x. Epub 2012
Sep 19. [PMID: 22994865: Full online text].
7. American College of Sports Medicine Position
Stand. Exercise and physical activity for older
adults. Med Sci Sports Exerc, 1998;30(6):992–
1008. PMID: 9624662
8. Spirduso WW, et al. Exercise dose-response
effects on quality of life and independent living
in older adults. Med Sci Sports Exerc, 2001; 33(6
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Suppl):S598–608; discussion S609-10. PMID:
11427784
9. A Guide to Medication Review, 2008.
We b s i t e : h t t p : / / w w w . n p c i . o r g . u k /
medicines_management/review/medireview/
library/5mg_medreview.php
10. Evans L, et al. The problem of non-compliance
with drug therapy. Drugs. 1983;25:1983.
11. McDonnell PJ, et al. Hospital admissions
resulting from preventable adverse drug
re a c t i o n s. A n n P h a r m a c o t h e r. 2 0 0 2 ;
36(9):1331–6.PMID: 1219604
12. Daniel E Everitt. Preventing adverse drug
reactions. In: Forciea MA et al. Editors-
Geriatric Secrets. Jaypee Brothers Medical
publishers, 1st Ind. Ed.:108.
13. Le Couteur David G, et al. Prescribing in older
people. Austr. Fam Physician, 2004;33(10):
777–81.
14. Le Couteur David G, et al. Prescribing in older
people. Austr.Fam Physician, 2004;33(10):
777–81.
 7
Section

Palliation and
Bereavement
™™ Communicating Bad News
™™ Palliative Care: Principles
™™ Palliative Home Care
™™ Family and the Grief Process

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 30
“If we, as a caring profession – in which I include all specialties – cannot, or will not, acknowledge the
fundamental need to take time to communicate with our patients, without whom our existence would be
unnecessary, what sort of professionals are we?”
Introduction
Breaking bad news to patients is one of the
most difficult responsibilities in the practice
of medicine. Virtually all physicians in clinical
practice encounter situations entailing bad
news. Yet medical education typically offers
little formal preparation for this daunting
task. However, the increased importance
noted by current literature in family medicine
on end-of-life issues reflects the desire on
the part of society to collaborate with their
family physicians in dealing with such issues.
Family physicians who provide continuity
of care to patients are in an ideal position
to compassionately, yet clearly, convey bad
news. The importance of physician-patient
relationship in such engagements is critical.
Having already developed a sense of mutual
trust, the family physician is often in a position
to break such news.
What is Bad News?
It is generally defined as “any news that
drastically and negatively alters the patient’s
views on his or her future”.1
Bad news is typically associated with
terminal illness such as cancer and AIDS.
However, bad news is not confined to issues
around terminal and incurable illness, death
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COMMUNICATING
BAD NEWS
Alison Franks
and dying. Bad news can come in many forms,
e.g. a treatment plan that is burdensome,
painful or costly, like end stage renal disease
requiring renal transplant; resistant angina
requiring CABG; loss of vital bodily function,
like loss of vision, amputation of an extremity;
a pregnant women’s ultrasound reporting
fetal death; diagnosis of a chronic illness, like
multiple sclerosis and juvenile diabetes.2
There are many factors, which may influence
the individual’s perception of the news, making it
‘bad’ for that particular person at that particular
time. Patient’s or family’s previous experiences,
expectations, anxiety about treatment
possibilities, financial implications, cultural
impact, society’s attitude and similar factors are
important in the context of ‘bad’ news.
The manner in which the bad news is given
also affects its impact, e.g. the words used, the
setting, the demeanour of the giver, the time
allowed, the place of discussion, and whether
it is one-or-two way exchange.
Why is Breaking Bad News So
Difficult?
Breaking bad news is one of the most important
and challenging physician’s duties in routine
daily work. However, there are many reasons
why physicians have difficulty breaking bad
 296  Section 7: Palliation and Bereavement
news. Table 30.1 shows some feelings of doctors
which may affect their ability in communicating
bad news with patients and families.
In a cross-sectional study conducted
using a questionnaire administered to a total
of 458 practicing physicians working in both
hospitals and Primary Healthcare centers,
it was concluded that although most of the
participating physicians were keen to help their
patients, they lacked the essential knowledge
and skills for breaking bad news. Thus, they
needed specific training in this regard.3
The present teaching in medical schools
emphasize on ‘biomedical model’ that values
technical skills more than communication skills,
especially how to demonstrate clinical empathy.
Medical education typically offers little formal
preparation for this daunting task. Without
proper training, the discomfort and uncertainty
associated with breaking bad news may lead
physicians to emotionally disengage from
patients.4,5 Rabow and McPhee, in their article,
“Beyond breaking bad news, how to help patients
who suffer,” sum up the end result, “clinicians
focus often on relieving patients’ bodily pain, less
Table 30.1 Adverse feeling of doctors on breaking
bad news
• Fear of hurting or upsetting the recipient
• Fear of adverse response from the recipient
• Uncertainty about how to react to the recipient’s
reaction
• Fear of being blamed
• Shame and feeling guilty of self-inadequacy and
impotence
• Worry over the questions they may be asked
• Anger of mistakes made by patient or family
• Anger of non-compliance made by patient or
family
• Anger of mistakes made by other health
professionals
• Sadness which we, as professionals, tend to
suppress in front of patients
Source: Franks A. Breaking bad news and the challenge of
communication, European J Palliat Care, 1997;4(2):61-65.
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often on their emotional distress, and seldom on
their suffering.”6
The way physicians break bad news
to patients with poor prognosis may have
been retrospectively associated with poor
psychosocial outcomes for patients e.g. in the
past Hippocrates advised, “concealing most
things for the patient while you are attending to
him. Give necessary orders with cheerfulness
and serenity, revealing nothing of the patient’s
future or present condition. For many patients
who have taken a turn for the worse…by
forecast of what is to come.”7
Further, in the past, practicing physicians
were taught to ‘protect’ patients from
disheartening news. This is evident from the
American Medical Association’s first code of
medical ethics (1987) which states, “The life of
a sick person can be shortened not only by the
acts, but also by the words or the manner of a
physician. It is, therefore, a sacred duty to guard
himself carefully in this respect, and to avoid all
things which have a tendency to discourage the
patient and to depress his spirits.”
Thus, the fear to being exposed to unexpected
strong emotional reactions by the patient, such as
aggression or despair, may cause the physician
to adopt unproductive coping strategies such as
discussion about technical details while avoiding
to deliver the main message.
Physicians also have their own reasons
about breaking bad news. It is an unpleasant
task. Physicians do not wish to take hope
from the patient. They may be fearful of the
patient’s or the family’s reaction to the news
or may not be able to deal with an intense
emotional response. The atmosphere or the
circumstances may not be congenial to deliver
bad news, or other responsibilities may be
competing for the physician’s attention.
Although, several professional groups have
published condensed guidelines on how to
discuss bad news, their clinical efficacies of
recommendations have not been empirically
 Chapter 30: Communicating Bad News 297
demonstrated. 8 As a result, emphasis on
training in communication skills, i.e. how to
break bad news is lacking in many physicians.
Therefore, physicians may feel unprepared to
deal with the intensity of the braking bad news,
or they may injustifiably feel that they have
failed the patient.
Some patients have multiple physicians,
making it unclear who should break the bad
news. The cumulative effect of these factors
is physician uncertainty and discomfort,
and a resultant tendency to disengage from
situations in which they are called to break bad
news.
Factors that can make breaking bad news
difficult for health professionals may be
summarized as follows:
™™ Fear of hurting or upsetting the receiver
™™ Fear of being blamed
™™ Feeling of “failing” the patients
™™ Anxieties over how they may respond and
how to deal
™™ Worry over the questions being asked
™™ Possibly having to admit one doesn’t know
all the answers
™™ Awareness of lack of knowledge, especially
in respect of treatment options and
prognosis
™™ Feeling inadequately trained or prepared
for handling such sensitive human inter-
reactions
™™ Uncertainty about how one should react in
front of the receiver and thereafter.
The last three factors mentioned above may
be major issues, especially for inexperienced
junior doctors who may feel particularly
vulnerable because of their limited experience,
scant knowledge of prognosis and highly
specialized treatment options.
*Paternalism in the context of healthcare is constituted by any action, decision, rule, or policy made
by a physician or other care-giver, or a government, that dictates what is best for the patient(s) without
considering the patient’s own beliefs and value system and does not respect patient autonomy which refers
to the capability and right of patients to control the course of their own medical treatment and participate
in the treatment decision-making process.
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Importance of Disclosure
In recent decades, the paternalistic model
of patient care has been replaced by one
that emphasizes patient autonomy and full
disclosure.* Honest disclosures of diagnosis,
prognosis and treatment options allow patients
to make informed healthcare decisions that are
consistent with their desires and values. When
physicians withhold bad news, they diminish
patient autonomy. Furthermore, the patient
will eventually learn the true nature of his/her
illness. Patients who discover that information
has been withheld may no longer trust their
physician.
Physicians have a legal obligation to obtain
informed consent from the patient and have
a moral, ethical, and legal duty to inform the
patient of the news, unless the patient refuses.
Moreover it is important to recognize that,
while any news – good or bad – is offered,
not all patients want active involvement in
decision making. At times the physician may
be requested not to tell the nature of illness
to the patient in order to ‘just to keep up the
morale’, or to suppress strained relationship
issues, or to suppress dysfunctional family
dynamics.9
What Patients Value
The most important factors for patients
when they receive bad news are physician’s
honesty, attention, competence, time
allowed for questions, a straightforward and
understandable diagnosis, and use of clear
language. Besides, patients expect high levels
of empathy and information quality, no matter
how bad the news.
Families rank privacy, physician’s attitude,
competence, clarity, and time for questions as
 298  Section 7: Palliation and Bereavement
important. Knowing the physician well and the
physician’s use of touch (e.g. holding patients
hand) rank lower.10,11
How Should Bad News be
Delivered?
Communicating bad news, as Franks 12
observes – “It is not an isolated skill but a
particular form of communication”, which
has to be delivered most compassionately and
effectively.
Rabow and Mcphee 6 have developed
a practical and comprehensive model,
synthesized from multiple sources10,12,13 which
uses the simple mnemonic ABCDE (Tables
30.2 and 30.3), and serve as a general guide
and most common recommendations to
physicians for breaking bad news.
A dv a nc e P r e pa r a ti on: P r e pa r e
Yourself to Feel Bad
Breaking bad news should be done in private
only; the patient, his/her loved ones, and the
members of the healthcare team should be
present. family’s emotional reaction; repeat at each visit
The physician should have all the basic
information and knowledge about the patient’s
illness, prognosis and treatment options.
The physician should sit down to facilitate
eye contact, face the recipient with eyes at the
same level and keep an unhurried attitude.
The physician should mentally practice on
how to deliver the news in a composed and
compassionate manner, e.g.
™™ “I wish I had better news”, as opposed to “I
am sorry, I have bad news”, “I admire your
courage.”
Build a Therapeutic Environment/
Relationship
Ask: Physicians, after their introduction,
should ask members of the patient’s family
their names and relationships to the patient;
check who everyone is.
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Table 30.2  The ABCDE mnemonic for breaking bad
news
• Advance preparation
–– Arrange for adequate time, privacy and no
interruptions (turn pager off or to silent mode)
–– Review relevant clinical information
–– Mentally rehearse, identify words or phrases
to use and avoid
–– Prepare yourself emotionally
• Build a therapeutic environment/relationship
–– Determine what and how much the patient
wants to know
–– Have family or support persons present
–– Introduce yourself to everyone
–– Warn the patient that bad news is coming
–– Use touch when appropriate
–– Schedule follow-up appointments
• Communicate well
–– Ask what the patient or family already knows.
–– B e f r a n k b u t c o m p a s s i o n a t e ; a v o i d
euphemisms and medical jargon
–– Allow for silence and tears; proceed at the
patient’s pace
–– Have the patient describe his or her
understanding of the news; repeat this
information at subsequent visits
–– Allow time to answer questions; write things
down and provide written information
• Deal with patient and family reactions
–– Assess and respond to the patient and the
–– Be empathetic
–– Do not argue with or criticize colleagues
• Encourage and validate emotions
–– Explore what the news means to the patient
–– Offer realistic hope according to the patient’s
goals
–– Use interdisciplinary resources
–– Take care of your own needs; be attuned to
the needs of involved house staff and office
or hospital personnel
Source: Adapted from Rabow MW, McPhee SJ. Beyond
breaking bad news: how to help patients that suffer. West J
Med. 1999;171:261.
Physicians need to get permission to share
bad news and how the patient would like to
get others involved. Asking permission lets the
family know that they need to focus on you as
you are going to give information. Ways to do
this include:
™™ “Is this a good time for me to talk about what
has happened since your dad was admitted?”
 Chapter 30: Communicating Bad News 299
Table 30.3  Frame work for communicating bad news
• Preparation:
–– Familiarize yourself with all the clinical
information
–– Have the case notes with you
–– Ensure adequate time for discussion; no
interruptions
–– Find a location with adequate privacy,
comfortable sittings facing at eye level
• Knowledge:
–– Assess patient’s current understanding and
thoughts
–– Check what has been told and what has been
understood (e.g. word ’tumor’ does not mean
‘cancer’ to everyone)
–– Explore how much that patient wants to know
• Inform the news:
–– Provide information honestly, but sensitively,
without emphasining
–– Use simple, every-day language
–– Watch for body language
–– Provide comfort as appropriate – say ‘sorry’ or
‘pardon’ or ‘I don’t know’
–– Use drawings, leaflets to reinforce
• Respond to the patient’s emotions:
–– Allow others to express their emotions and
empathize
–– Don’t argue or crticise colleagues  
• Treatment options:
–– Offer to discuss implications of the news
–– Give brief updated information
–– Allow time for informed decision making and
consent:
–– Discuss prognosis
• Offer additional resources:
–– Other support services, specialist nurse
• Summarize the discussion:
–– Check back on important points
–– Ask if there are any other questions
–– Give realistic hope as appropriate
• Follow-up meeting:
–– Future plan for patient and family questions
and concerns
• Document the discussion in the medical record
™™ “Would you like to hear our recommendation
about what should be done?”
Tell: Sufficient time should be allowed to
answer questions. Interruptions (e.g. cell
phones) should be minimized. Deliberate
periods of silence allows patient to process
bad news and ventilate emotions. Physicians
should add few emphatic statements, e.g.
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™™ “I understand how you feel”; “I can see that
you are upset by this news”.
Tell me more: Encourage them to ask questions.
Make sure that every question is answered. It
is alright to show ignorance and uncertainty.
Touch: Use touch wherever appropriate,
but be sensitive to cultural differences and
personal preference. As physicians, we have
the opportunity to ‘touch’ our patients at many
levels – physically, emotionally and spiritually.
Communicate Well: Deliver Bad News
Clearly and Unequivocally
Physicians need to have prior knowledge
of what the patient knows about his/her
illness before breaking bad news. Assessing
patient perceptions allows the physician to
correct misinformation and tailor the news
to the patient’s level of comprehension.
Undue bluntness and misleading information
should be avoided. Frank, compassionate
communication in simple language and
proceeding at the patient’s pace is essential. It
may be tempting to use euphemisms to soften
the delivery of bad news, but by doing so one
can be extremely misleading and create a
good deal of confusion. (Don’t say, “There’s a
lesion in your chest X-ray” or even “You have
a tumor;” say, “You have cancer”).
There is nothing wrong in using ‘D’
words—“dead—died or dying” if they are
accurate. Using honest words is integral to
effective communication and minimizes
confusion. At the conclusion of each visit,
summarize and make follow-up plans.
Deal with Patient and Family Reactions
Physicians should assess and respond to
patient’s emotional reactions and should possess
cognitive coping strategies while dealing with
fear, anger, shame, sadness and guilt experienced
by the patient and his family members.
Be composed. Do not argue with or criticize
colleagues. Remember practical things – giving
 300  Section 7: Palliation and Bereavement
information about where to obtain death
certificate, legal formalities like postmortem and
how to organize cremations may all seem far
from the clinical side that we are trained for, but
they are of importance to the patient’s relatives.
Encourage and Validate Emotions:
Never Destroy Hope
Discuss treatment options and offer realistic
hope and encouragements and develop
strategies to realize them.
Physicians should assure the patient of
their availability to address symptoms, answer
questions and meet other needs.
Inquire about patient’s emotional and
spiritual needs and means available to fulfill
them. The knowledge of spiritual beliefs gives
us an insight about how they may cope with
illness or how their beliefs might influence
their decisions regarding treatment. When
appropriate pray with patient and relatives.
Doing so will show your support for their beliefs.
At the end, summarize the family concerns
and problems to show that the problems have
been understood. Explore the options with
the patient. Let the patient make decisions.
Offer further meetings or channels of
communication. Offer referrals as needed. Use
interdisciplinary services to enhance patient
care e.g. hospice services.
Communication in Specific
Situations
Using the Telephone
Frequently in critical care practice, information
needs to be conveyed urgently to a patient’s
family. When the family is not available at
the hospital, a telephone call is necessary.
This need for urgent communication most
often occurs when a patient’s condition has
become suddenly worse, or in the event
of an unexpected death at night hours.
When communicating by telephone, pausing
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frequently is even more important than
when communicating face-to-face, because
expressions and other body language cannot
be used to check for understanding.
In general, it is preferable to keep the
telephone conversation as brief as possible
without appearing abrupt or insensitive, and
urge the family to come to the hospital so that
a meeting can take place.
In some situations, before any urgent need
for notification, it may be appropriate for a
physician to find out whether family members
wish to be notified by telephone about changes
in a patient’s condition (including notification
of death) or whether they wish to be asked to
come to the hospital.
Using a Translator
If there is a language barrier it is important
to enlist the service of a translator skilled in
medical terminology and communication,
to ensure effective and accurate delivery. If
possible, avoid using a family member as a
translator, because he/she may not be the best
person to communicate medical information.
Also, in the role of a translator, a family member
may tend to supplement the information being
conveyed, withhold information, or otherwise
soften the delivery in an effort to protect the
patient. The potential for a family member to
“editorialize” the information is great. Always
be sure to face the patient when speaking; your
eye contact should be with the patient, not the
translator.
The Future
Although delivering bad news is something
that occurs daily in most medical practices,
the majority of clinicians have not received
formal training in this essential and important
communication task. A variety of models are
currently being used in medical education
to teach skills for delivering bad news. For
example, simulation-based education,
 Chapter 30: Communicating Bad News 301
videotaped role-plays and the subsequent
video-based analyses are rapidly developing
method of supplementing and enhancing
the clinical education of medical students.
Clinical situations are simulated for teaching
and learning purposes, creating opportunities
for deliberate practice of new skills without
involving real patients.14,15
Courses and seminars concerning end-of-
life care and spirituality are becoming more
prevalent. One is a joint venture between the
American Medical Association (AMA) Institute
of Ethics and the Robert Wood Johnson
Foundation, entitled Educating Physicians on
End-of-life Care (EPEC).16
In addition, courses are available in
many countries providing EPEC training to
interested family physicians, primary care
professionals and allied healthcare workers.
In India, project Education in Palliative
and End of Life Care in India (EPEC-India) has
been developed to augment the education of
professionals and the volunteers in palliative
care.*
Conclusion
Dying patients need their physician’s
presence—not necessarily to attend to their
ailing problems, but to express, hear and be
understood with respect and empathy. It is
in this context the communication skills are
vitally important.
A growing body of evidence demonstrates
that physician’s attitude and communication
skills play a crucial role in how well patients
cop e w ith bad news. Higher quality
communication and increased physician’s
knowledge of patient’s wishes is associated
with greater satisfaction.
The training of a family physician and his
practice philosophy support open and honest
communication between the physician and
*Website: http://palliumindia.org/about/epec/
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patient. As a result, family physicians are in an
ideal position to help patients with a disease,
face their illness with compassion and dignity.
“To manage bad news well, the clinician
must place his/her relationship with the
patient, the strength and reality of their human
bond, over the insecurity of disease, the threat
of dissolution, and the fear of death. Breaking
bad news is not as much a delivery as it is a
dialogue between two people, both striving
to discover in each other a simple faith in
the future and an understanding of meaning
beyond themselves.”
References
1. Buckman R. Breaking bad news- why is it so
difficult? BMJ, 1984;288:6430,1597–9.
2. VandeKieft GK. Breaking bad news. Am
Fam Physician, 2001;64(12):1975–8. [PMID:
11775763: Free Article].
3. Al-Mohaimeed AA, et al. Breaking bad news
issues: a survey among physicians. Oman Med
J, 2013;28(1):20–5. doi: 10.5001/omj.2013.05.
[PMID:23386940:Free PMC Article].
4. Afghani B, et al. Medical students’ perspectives
on clinical empathy training. Educ Health
(Abingdon), 2011;24(1):544. Epub 2011 Apr 9.
[PMID: 21710425: Abstract].
5. Ali AA. Communication skills training of
undergraduates. J Coll Physicians Surg Pak.
2013;23(1):10–5. doi: 01.2013/JCPSP.1015.
[PMID:23286616:Abstract].
6. McPhee SJ, et al. Beyond breaking bad news:
how to help patients who suffer. West J Med,
1999;171:260–3.
7. Hippocrates. Decorum, XVI. In: Jones WH,
Hippocrates with an English Translation. Vol
2. London: Heinemann, 1923.
8. Girgis A, et al. Breaking bad news: consensus
guidelines for medical practitioners. J Clin
Oncol, 1995;13(9):2449–56. [PMID: 7666105:
Abstract].
9. Chhablani RK. How to Deliver a Terminal
Diagnosis to Patients: A Helpful Approach.
American Medical Association Institute for
 302  Section 7: Palliation and Bereavement
Ethics. Education for Physicians on End-of-life
Care (EPEC) Participant’s Handbook. Chicago:
American Medical Association; 1999.
10. Jurkovich GJ, et al. Giving bad news: the family
perspective. J Trauma, 2000;48(5):865–70;
[PMID: 10823529: abstract].
11. Ishaque S, et al. Breaking bad news: exploring
patient’s perspective and expectations. J
Pak Med Assoc, 2010;60(5):407–11. [PMID:
20527623: Abstract].
12. Franks A. Breaking bad news and the challenge of
communication. Eur J Palliat Care, 1997;4: 61–65.
13. Baile, et al. SPIKES – A six-step protocol for
delivering bad news: application to the patient
with cancer. Oncologist 2000;5(4):302.
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14. Rosenbaum ME, et al. Teaching medical students
and residents skills for delivering bad news: a
review of strategies. Acad Med, 2004;79(2):107–
17. [PMID: 14744709: Abstract].
15. Kopecky-Wenzel M, et al. Breaking bad news-
-a video-based training unit for medical
students.Z Kinder Jugendpsychiatr Psychother,
2009;37(2):139–44. doi: 10.1024/1422-
4917.37.2.139. [PMID: 19402001: Abstract].
16. EPEC project: Education for physicians on end-
of-life-care, 1998, AMA, Institute of ethics.
17. Quill TE, et al. Bad news: delivery, dialogue, and
dilemmas. Arch Intern Med, 1991;151(3):463–
8. [PMID: 2001128: Full text].
 31
“You matter because you are you. You matter to the last moment of your life, and we will do all we can,
not only to help you die peacefully but also to live until you die”.
Recognizing Dying
Eventually, every one dies. Despite all the
success of medical progress, and physician’s
spirited battle to prevent dying by the
application of biomedical technology, which
may successfully extend life and make dying
more protracted, death inevitably comes.
If dying really is an inevitable natural
process of the life cycle, reintegration of the
dying patient into the routine course of living
is necessary. Therefore, providing excellent
humane care to patients near the end of life,
when curative means are either no longer
possible, or no longer desired by the patient,
is an essential part of medicine.
Medical organizations all over the world
recognize that most people near the end of life
want to live as fully as they can. They want their
health care providers to honor their wishes and
goals, and to help them maintain their dignity
and independence while relieving symptoms
and maximizing comforts.
For physicians and health care providers,
to provide excellent care to dying patients and
their families, they need expertise as well as
compassion.* Physicians who care for dying
patients often find this work fulfilling, a source
of pride, and even a privilege.1
*As Sir William Osler stated, our goal as physicians is "to cure sometimes, to relieve often, and to comfort always."
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PALLIATIVE CARE:
PRINCIPLES
Dame Cecily Saunders
Founder of the modern hospice movement
The Need for Palliative Care2
Nu m e ro u s s t u d i e s 3 , 4 c o n f i r m e a r l i e r
observations that, while receiving expensive
care that is concentrated on pathophysiology
and treatment of disease, dying people and
their families experience a wide range of
patients’ unmet needs for their symptom
such as amelioration of severe pain, disability,
emotional trauma, and depression. In such
precarious life-and-death situations—when
the burdens of treating an illness outweigh
the benefits—the goal of a patient’s care may
change from curing to comfort, so that the
patient can find solace in the time remaining
and achieve personal goals at the end of life.
Many patients die with high ‘symptom
burden’—such as severe pain, weakness,
fatigue, anorexia, weight loss, and dyspnea—of
preventable suffering. Family members often
experience social and financial devastation,
having to quit a job, or suffering major losses of
income, or savings because of life-threatening
illness.
Recent studies indicate that not only
doctors seem reluctant to speak to patients
about death, but also that they give inaccurate
optimistic views about the future course of the
illness. Physicians acknowledge that it is easier
 304  Section 7: Palliation and Bereavement
to continue treating than to make a decision to
stop, thus avoiding difficult conversations or
ethical decisions,5 thus delaying timely sharing
of information and referral to appropriate
palliative care services.6
Palliative care is an important means of
relieving symptoms that result in undue suffering
and frequent visits to the hospital or clinic. Lack
of palliative care results in untreated symptoms
which hamper individual’s ability to continue
his/her activities of daily life. At the community
level, lack of palliative care places an unnecessary
burden on hospital or clinic resources.7
Providing end-of-life care services improves
patient and family satisfaction while reducing
overall costs through decreased use of acute
hospital care. Contrary to some expectations,
studies demonstrate palliative care significantly
prolongs life among selected patient populations.
Studies have shown that patients who received
early palliative care in the ambulatory care
setting, as compared with patients who
received standard oncologic care, would have
a better quality of life, lower rates of depressive
symptoms, and less aggressive end-of-life care.8
Special Role of the Family
Physician
The family physician is an ideal person to
manage palliative care for a variety of reasons,
such as availability, knowledge of the patient
and family, and the relevant psychosocial
dynamics of the family. Besides, by virtue
of their lifelong association with patients,
most family physicians practice some form
of palliative care, although variations exist in
different health care settings regarding the
degree of technologic intervention at the end
stage of life.
Typically, family physicians provide care
through life, which strengthens their trusting,
ongoing relationship with most of the family
members over time. Thus, they are skilled
advocates for patients and their families in all
aspects of health care. Also, by virtue of their
training and practice, family physicians are in
a unique position to champion the philosophy
of terminal care to their families. A key feature
of family physicians is their ability to provide
patients the essential care at home.9,10
Another area wherein family physicians can
gainfully utilize their expertise is in the field of
pediatric palliative care.11,12 Although the pattern
of morbidity and mortality in children may be
different from those in adults, it is the parents
who are usually the main guardians for ailing
children, with care taking place at home.13 Many
children have prolonged ‘life-limiting illness’
for which no curative treatment is available and
in which premature death is likely, e.g. cerebral
palsy, mucopolysaccharoidise, cystic fibrosis and
HIV/AIDS.14,15 The intimate family relationship
which the family physicians develops with
such suffering families facilitates them to play
an active palliative role, providing support to
the ailing child, child’s siblings and the family
members.
What is Palliative Care?
Modern Palliative care has its origin in the
opening of St. Christopher’s Hospice in
London in 1967, under the leadership of Cicely
Saunders.* The first patient was admitted on
13 July 1967 and the official opening followed

*Born 22 June 1918 in Barnet, England, Dame Cicely was trained as a nurse, a medical social worker and
finally as a physician. She was involved with the care of patients with terminal illness since1948. She is
recognized as the founder of the modern hospice movement She founded St. Christopher's Hospice in
1967 as the first research and teaching hospice linked with clinical care, pioneering the field of palliative
medicine. During her career, Saunders received many awards for her pioneering work, including the
Templeton Prize in 1981, and wrote and edited a number of books on her subject. She was made a Dame
of the British Empire by Queen Elizabeth II in 1980.Dame Cicely died on 14 July 2005 at St Christopher's
Hospice, London.

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 Chapter 31: Palliative Care: Principles 305
The History of Palliative Care
In the early development of medical care, palliative
care was one of the few effective services physicians
could provide. Physicians were unable to offer cures
for most life-threatening illnesses but worked instead,
within the long tradition of “healers,” to provide solace
and comfort to the ill.
With the emergence of medicines and technologies
that enabled physicians to postpone death of many
patients, the focus of medical care shifted to curative
attempts.
More recently, the realization that for some there
may be “fates worse than death” (that is, prolonged
unrelieved suffering, overly aggressive technological
intervention, and loss of dignity at the end of life) has
led to the modern hospice movement.
Palliative care is a further development of this
idea, recognizing that an either/or choice between
curative care and hospice care is neither necessary
nor desirable for most people with terminal illness
Source: Palliative Care in California: Fundamentals of
Hospital-Based Programs. Web site: http://www.chcf.org/~/
media/MEDIA%20LIBRARY%20Files/PDF/P/PDF%20
PalliativeCareFundamentals.pdf
shortly on 24 July 1967. A holistic approach,
caring for a patient’s physical, spiritual and
psychological wellbeing, marked a new
beginning, not only for the care of the dying but
for the practice of medicine as a whole. Since
then palliative care has developed around
the world;* and has irreversibly improved the
standards of care for the dying.
However, as palliative care has developed
in different ways in different countries,
questions have been raised as to how palliative
care should be defined, what it should be
called —is it synonymous with terminal care,
care of the dying, end-of-life care, hospice care;
and what is its scope.
The terms ‘palliative care’, ‘care of the dying’
and ‘end-of-life-care’ imply a focus on care of
the whole person who is approaching death
rather than on an attempt to cure the underlying
*Ref. web sites: http://www.medhealthwriter.com/_mgxroot/page_10814.html;
http://www.carebeyondcure.org/inindia.htm; and
http://www.hospicecare.com/global-palliative-care/global-directory-of-education-programs/
**Ref. Chapter 8: The spectrum of clinical diagnosis
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disease. Since, it emphasizes that the dying
process is a part of life, the expression ‘end-of-
life-care’ is preferred by some authors.16 End-of-
life care is provided to patients in the last days,
weeks, and months of life.
The ‘spectrum of palliative services’
includes palliative care that can be provided
both by hospice programs and by non-hospice
care, across all medical settings, including in
the hospital, at home, and in nursing facilities.
There are various definitions of palliative
care. The most straightforward is that of the
National Council for Hospice and Specialist
Palliative Care Services, which is based on
an earlier definition from the World Health
Organization:17
“Palliative care is the active total care of
patients whose disease is not responsive to
curative treatment. Control of pain, of other
symptoms and of psychological, social and
spiritual problems is paramount. The goal of
palliative care is achievement of the best possible
‘quality of life’ for patients and their families”.
A ‘holistic approach’, i.e. ‘patient centered
approach’ (biopsychosocial model—Table
31.2), rather than a ‘disease centered approach’
(biomedical mode), is the underlying
philosophy of palliative care.** It is concerned
with physical, psychological, social, and
spiritual aspects of care. The patient is not seen
as an individual, but as a part of a family unit.
Interdisciplinary team, generally consisting
of nurses, social workers, home health aids,
physical therapists, personal caregivers,
chaplains, volunteers, and the patient’s family;
working and supporting each other achieve
effectively the holistic approach to the patient’s
care, and this is the principle which has been
central to the development of palliative care.
 306  Section 7: Palliation and Bereavement
In practical terms, the fundamentals of
palliative care can be described as: symptom
control, rehabilitation, continuity of care,
and terminal care. This process emphasizes
that palliative care, which begins long before
end-stage care, and instituted throughout the
course of any serious, chronic, and terminal
illness for which curative treatment is neither
possible nor appropriate, and from which
death is certain. This varies from a few days to
many months.
The United Kingdom’s Policy Framework
for Commissioning Cancer Patients18 states
that, “Palliative care should not be associated
exclusively with terminal care. Many patients
need it early in the course of their disease,
sometimes from the time of diagnosis. The
palliative care team should integrate in a
seamless way with all cancer treatment
services to provide the best possible quality
of life for the patient and their family.” A
shared-care approach between palliative
care specialists and other disciplines has
been found to be helpful in ensuring that
care is adaptive and responsive throughout
the patient’s disease trajectory, particularly
where there is a complexity of symptoms.
Therefore, the overall scope of palliative care is
much broader and may be needed for months
or even years.19,20 The relationship between
palliative and curative care is depicted in
Figure 31.1.21
Fig. 31.1  The scope of palliative care
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The overall philosophy of palliative care
fit the chronic disease model, i.e. any place,
any time; outpatient, inpatient, or the home,
with home care supported with other medical
and paramedical systems; regardless of the
prognosis, whether the goal is to cure disease,
or manage chronic illness.
Principles of Palliative Care22
(Table 31.1)
Palliative care improves the quality of life of
patients and families who face ‘life-threatening
illness’, such as cancer, congestive heart failure,
chronic obstructive pulmonary disease, kidney
failure, Alzheimer’s, Parkinson’s, Amyotrophic
Lateral Sclerosis and many more.
Palliative care focuses on relief of symptoms
such as pain, shortness of breath, fatigue,
constipation, nausea, loss of appetite, difficulty
sleeping and depression, and provides spiritual
and psychosocial support to the end of life and
bereavement. Palliative care:
™™ Provides relief from pain and other
distressing symptoms
™™ Affirms life and regards dying as a normal
process
™™ Intends neither to hasten or postpone
death
™™ Integrates the psychological and spiritual
aspects of patient care
 Chapter 31: Palliative Care: Principles 307
Table 31.1  Principles of palliative care
Holistic Care of the body, mind and spirit;
approach focusing on social, emotional, Cultural,
and spiritual aspects of care, supported
by an interdisciplinary team and training
Quality of Patient centered approach, incorporating
life respect for patients’ values and
preferences, promotes autonomy in
decision making, and attends to the
needs of physical and emotional support
Ongoing Ongoing end-of-life-care to illness
care to such as cancer, AIDS, cardiac failure,
Life- dementia, cerebral palsy, cystic
threatening fibrosis, metabolic disorders and
and life- many more
limiting
illness
Patients Helps the patient and family understand
and the illness and choices for care,
families offers guidance and support with
difficult medical decisions, assists with
communication between medical staff,
ease transition between healthcare
settings, offers compassionate family
support
™™ Offers a support system to help patients live
as actively as possible until death
™™ Offers a support system to help the family
cope during the patients illness and in their
own bereavement
™™ Uses a team approach to address the needs
of patients and their families, including
bereavement counseling, if indicated
™™ Will enhance quality of life, and may also
positively influence the course of illness
™™ Is applicable early in the course of illness,
in conjunction with other therapies that
are intended to prolong life, such as
chemotherapy or radiation therapy, and
includes those investigations needed to
better understand and manage distressing
clinical complications.
Tasks in Palliative Care and Care
of the Dying
As people approach the end of their lives,
physicians and their families commonly face
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Table 31.2  Biopsychosocial model23
• Physical:
–– Relief of symptoms—both pain and non-pain
symptoms
• Psychological:
–– Safety—feeling of security
–– Understanding—explanation about symptoms/
disease; opportunity to discuss the process
of dying
–– Self-esteem—involvement in decision-making;
opportunity to give as well as to receive
• Social:
–– Acceptance—non-condemnatory attitude in
the guardians, regardless of one’s mood,
appearance, or social class
–– Belonging—a feeling of need; not a burden
–– Disengagement—to hand over responsibility
to others; to tie up lose ends in business and
family matters
• Spiritual:
–– Love—expression of affection, touch
–– Reconciliation—to seek forgiveness
–– Self worth—knowledge that one is loved and
valued
–– Purpose—feeling one’s life has meaning and
direction
complex medical tasks and decisions related
to the terminal illness, which have significant
impact on suffering and the quality of living
and dying.
The medical tasks and decisions related
to end-of-life are often the most challenging
for terminally ill people and those who care
about them. However, each of these decisions
should ideally be considered in terms of the
relief of suffering and the values and beliefs of
the dying individual and his/her family. These
mainly include the following:
™™ When death is approaching—diagnosing
death
™™ Patient family involvement—shared
decision-making
™™ Symptom management
™™ Support of family careers
™™ Support after death.
 308  Section 7: Palliation and Bereavement
When Death is Approaching: Table 31.3  Karnofsky performance status25-27

Diagnosing Dying20 Able to carry on Normal no complaints; no

normal activity 100 evidence of disease
Healthcare professionals (HCPs) have an and to work;
90 Able to carry on normal
important role in helping patients understand no special care
activity; minor signs or
needed
that their lives are ending. This information symptoms of disease
influences patient’s treatment decision and 80 Normal activity with effort;
changes how they may spend their remaining some signs or symptoms of
disease
life span. However, diagnosing dying is often a
complex process because even in the terminal Unable to work; 70 Cares for self; unable to
able to live at carry on normal activity or
stages various illnesses have variable and home and to do active work
difficult to predict prognosis. Nonetheless, care for most
60 Requires occasional assist­
clinical experience, epidemiological data, personal needs;
ance, but is able to care for
varying amount
guidelines from professional organizations, like most of his personal needs
of assistance
Hospice Centers, Computer Based Prediction needed 50 Requires considerable
Tools, Karnofsky Performance Status,* (Table assistance and frequent
medical care
31.3) and the Eastern Cooperative Oncology
Unable to care 40 Disabled; requires special
Group (ECOG) performance status (Table 31.4) for self; requires care and assistance
may be employed which help HCPs and patients equivalent of
30 Severely disabled; hospital
identify the end period of their lives. institutional or
admission is indicated
Recognizing the key signs and symptoms hospital care;
although death not imminent
disease may
is an important clinical skill in diagnosing be progressing 20 Very sick; hospital admission
dying. The dying phase for some disease can rapidly necessary; active supportive
treatment necessary
be precipitous, e.g. massive hemorrhage and
myocardial infarction; but is usually preceded 10 Moribund; fatal processes
progressing rapidly
by a gradual deterioration in functional status.
0 Dead
The following symptoms (Table 31.5) and signs
of active phase of dying (Table 31.6) are often
and then refocus care appropriately for the
associated with the dying phase, i.e. disability or
patient.
disease that is progressively worse until death.
In the course of patient’s terminal illness,
Patient—Family Involvement:
physicians do come across some barriers,
which either delay or prevent diagnosing dying Shared Decision Making**
(Table 31.7). In caring for patients at the end of life,
Once dying has been diagnosed, physicians physicians and health team members face
need to overcome the said barriers (Table 31.8) a number of unforceable situations in the

*The Karnofsky Performance Scale Index allows patients to be classified as to their functional impairment.
This can be used to compare effectiveness of different therapies and to assess the prognosis in individual
patients. The lower the Karnofsky score, the worse the survival for most serious illnesses.
**‘Shared decision making’ is a process in which clinicians and patients work together to select tests,
treatments, management or support packages, based on clinical evidence and the patient’s informed
preferences. It involves the provision of evidence-based information about options, outcomes and
uncertainties, together with decision support counselling and a system for recording and implementing
patients’ informed preferences. Source; Angela Coulter: In ‘Evidence: Helping people share decision
making’ June 2012; published by the Health Foundation, 90 Long Acre, London WC2E 9RA.

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 Chapter 31: Palliative Care: Principles 309
Table 31.4  ECOG performance status
Grade ECOG
0 Asymptomatic: Fully active, able to carry
on all pre-disease performance without
restriction
1 Symptomatic but completely ambulatory:
Restricted in physically strenuous activity
but ambulatory and able to carry out work of
a light or sedentary nature, e.g. light house
work, office work
2 Symptomatic, <50% in bed during the day:
Ambulatory and capable of all self-care but
unable to carry out any work activities up
and about more than 50% of waking hours
3 Symptomatic, >50% in bed, but not
bedbound: Capable of only limited self-care,
confined to bed or chair more than 50% of
waking hours
4 Bedbound: Completely disabled. Cannot
carry on any self-care. Totally confined to
bed or chair
5 Dead
Table 31.5  Symptoms that can occur when a person
enters the dying phase
• Profound weakness
• Withdrawal from the world
• Reduced cognition
• Reduced levels of consciousness
• Reduced intake of diet and fluids
• Difficulty with swallowing medications
• Retained bronchial secretions (death rattle)
• Increased nausea and vomiting
• Terminal agitation
• Reduction in urine output
• Cessation of bowel movement
Source: Sykes (2004); The National Council for
Palliative Care (2006); Marie Curie Palliative Care
Institute (2007); Clark and Butler (2009); Morris (2009)
process of decision making policies about
how best to proceed with treatment, e.g.
what patients choose for themselves may
not be in unison with what the family or
physicians believe should be done. Even
between seemingly similar individuals,
treatment options may prove to be radically
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Table 31.6  Signs of active phase of dying
• Coma (inability to arouse patient at all) or, semi-
coma (ability to only arouse patient with great
effort but patient quickly returns to severely
unresponsive state)
• Agitation, hallucinations
• Apnea (transient cessation of respiration),
Cheyne-Stokes (cycles of respiration that are
increasingly deeper then shallower with possible
periods of apnea)
• Patient breathing through wide open mouth
continuously and no longer can speak even if
awake
• Death rattle (severely increased respiratory
congestion or fluid buildup in lungs
• Dysphagia (inability to swallow any fluids at all and
not taking any food by mouth voluntarily as well)
• Urinary or bowel incontinence in a patient who
was not incontinent before
• Oliguria (marked decrease in urine output and
darkening color of urine or very abnormal colors
such as red or brown)
• Blood pressure (BP) dropping dramatically from
patient’s normal BP (more than a 20 or 30 point
drop)
• Systolic blood pressure below 70 mm Hg, diastolic
blood pressure below 50 mm Hg
• Patient’s extremities (such as hands, arms, feet
and legs) feel very cold to touch
• Cyanosis or a bluish or purple coloring to the
patients arms and legs, especially the feet and
hands
• Jaw drop; the patient’s jaw is no longer held
straight and may drop to the side their head is
lying toward
Note: Hearing may be one of the last senses to be lost
- even up till the very end, even though he/she cannot
respond by speaking.
Source: Hospice patients alliance. Web site: http://www.
hospicepatients.org/hospic60.html
different. However, in such terminal care
of patients, physician must appreciate the
central role played by the patient and, where
appropriate, by family members in the process
of decision making policies; e.g. where the
patient may wish to die, statements regarding
will, decisions regarding futile treatment
and/or life-sustaining measures and organ
donation.
Initiating discussions on the transition
from curative care to palliative care can be
stressful for doctors, patients and families.
 310  Section 7: Palliation and Bereavement
Table 31.7  Potential barriers to diagnosing dying
• Hope that the patient may get better
• Concerns about with-holding or withdrawing
treatment
• Concerns about having the resuscitation
conversation
• Continuation of unrealistic and futile interventions
• Disagreement about the patient’s condition among
professionals
• Failure to recognize key symptoms and signs
• Lack of knowledge and/or experience of the
clinician particularly around end of life prescribing
• Inability to communicate with the patient and/or
their relatives
• Fear of shortening life or of litigation
• No definitive diagnosis
• Cultural or spiritual barriers
Most patients desire doctors to discuss these
issues. They may not ask about it openly
because of anxiety or fear of adverse impact.
However, physicians should voluntarily and
tactfully explore reasons for such a request and
ask the patient, “Do you have any questions?”
(Table 31.9). The challenge for doctors’ is to
maintain open communication and ‘shared
decision making’ with patients’ and family
members at this very sensitive time. Physicians
need merely to listen, accept the patient’s
feelings, and respond to their questions
positively and honestly, e.g. “I will keep you
as comfortable as possible”, “I will do my best
to fulfill your wish”.
Physicians can also help formalities in
various other areas of decision making by
modifying their approach. For examples,
™™ Improving communication—listen
carefully to family members, provide
guidance, particularly when the patient is
no longer able to make decisions about his/
her own healthcare
™™ Facilitate advance care planning by
focusing on patient’s wishes and discussion
with the family members
™™ Facilitate legal advance directives, e.g.
execution of a living will, organ donation,
autopsy and funerals.
™™ Following up with family after death.
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Table 31.8  Overcoming barriers to diagnosing dying29
• Work together – be a member of a multi
professional team
• Communicate sensitively on issues related to
death and dying
• Recognize key signs and symptoms of the dying
patient (Tables 31.5 and 31.6)
• Prescribe appropriately for dying patients:
–– Discontinue inappropriate drugs
–– Prescribe essential drugs, including for pain,
agitation, nausea, and vomiting
–– Prescribe subcutaneous drugs for delivery by
a syringe driver
• Consult “Ethical and Medicolegal Committee”
that deals with issues related to dying patients,
resuscitation withholding and withdrawing
treatment, fore shorting life and fatality.
• Refer appropriately to a specialist palliative care
team.
Table 31.9  Useful questions for determining terminally
ill patient’s needs and wishes
• Are you comfortable with the present care?
• What has been most difficult about this illness
for you?
• What do you fear most?
• How is your family dealing with your illness?
• What is your highest priority?
• What would you like to accomplish in the time left?
• How can I help you achieve this?
• Is religion important to you?
• Do you need assistance of priest?
Identification and Management of
Symptoms (Table 31.10)
A marked proportion of patients (though not
all) will develop new symptoms or worsening of
existing symptoms. Patients may not mention
these to the physician on the assumption
that nothing can be done to help, or they
may be exhausted and forget to mention.
Full examination may cause discomfort, so a
focused examination should be carried out.
Investigations have little if any role to play
in the end of life care. Common symptoms
include:
™™ Pain
™™ Agitation or restlessness
™™ Confusion
 Chapter 31: Palliative Care: Principles 311
Table 31.10  Symptoms, drugs used and management
Symptom Drugs and Treatment Comments
Pain • Paracetamol Opioids are the mainstay of pain
• NSAIDs management; combinations of NSAIDs and
• Tricyclic Antidepressants (nortriptyline, opioids are most commonly used. Respiratory
desipramine) depression uncommon. Concurrent use of
• Anticonvulsants (gabapentin) PPIs helpful to prevent gastrointestinal (GI)
• Opioids (morphine-oral/parenteral; hydro­ side effects. Steroids for nerve blocks in
codone, codeine; tramadol; fentanyl) neuropathic pain
• Steroids
Dyspnea • Opioids (including aerosolized morphine) Address underlying cause, e.g. cardiac
• Anxiolytics/Benzodiazepines disease, pneumonia, effusion, bronchospasm
• Oxygen
• Complementary Therapy (relaxation
technique)
Nausea & • Metoclopramide Reduce opioid dosage; address reversible
Vomiting • Cyclizine cases, such as constipation, hypocalcemia;
• Ondansetron stop all non-essential drugs
• Haloperidol
• Promethazine
• Steroids
Constipation • Bisacodyl/Senna Increase patient activity, fluid, intake, dietary
• Lactulose fiber; modify opioid dosage; provide privacy,
• Sorbitol toilet training
• Magnesium Citrate
• Enema
Confusion • Haloperidol Many causes, e.g. metabolic disorder,
• Chlorpromazine infection, side effect of a medication
Agitation, • Lorazepam Many causes: as above
Restlessness, • Midazolam
Delirium • Haloparidol
Noisy breathing/ • Hyoscine Dying with suffocation must be avoided
Death rattles • Glycopayrrolate
• Suction
Urinary • Catheterization
Incontinence/
Retention
Dry/Sore mouth • Good oral hygiene Rule out oral thrush
• Frequent Moistening
• Frequent sips of liquids
• Ice cubes
• Artificial saliva
Extreme fatigue • Steroids In selected cases blood transfusion may be
considered

™™ Dyspnea Care of the dying patients should focus

™™ Dyspepsia on the relief of symptoms, not limited to
™™ Extreme fatigue pain, and should use both pharmacological
™™ Noisy breathing and non-pharmacological means. There are
™™ Bladder—urinary incontinence/retention a variety of alternative and complementary
™™ Dry or sore mouth treatments available (TENS, acupuncture,
™™ Constipation. aromatherapy massage, hypnotherapy, etc.)

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 312  Section 7: Palliation and Bereavement
and local resources will vary. Many hospices
and hospitals now offer these treatments—
even for outpatients.
A multispecialty team approach to assess
and evaluate the symptom disability helps
to overcome or ameliorate the problems by
employing innovative therapeutic techniques
and creative solutions to restore or improve
the quality of life; e.g. many patients are unable
to swallow drugs during dying phase, and
medications must be given by parenteral
route, such as transdermal route, continuous
subcutaneous infusion, or syringe driver (Table
31.11). Drugs that can be administered using
syringe drivers include clonazepam, cyclizine,
diamorphine, dexamethasone, glycopyrronium,
haloperidol, hyoscine, ketamine, ketorolac,
metoclopramide, midazolam, morphine,
octreotide, ondansetron, and oxycodone.*
Symptoms should be treated as vigorously
as is appropriate to the patient’s situation and
preferences to maximize comfort, even if the
unintended effect of these efforts is on rare
occasions hastening of deaths.
The general principles of symptom
management can be summarized as follows:
™™ Determine the cause
™™ Offer suitable explanation of symptoms
™™ Treat simply as much as possible
™™ Give medication regularly round the clock
and ‘add on’ drugs when indicated
Table 31.11  Syringe driver—indications
• Acute pain
• Nausea and vomiting
• Dysphagia
• Intestinal obstruction
• Other inability to swallow or absorb drugs
• Rectal route inappropriate
• Semi-comatose/comatose patient
• Patient convenience (e.g. massive doses of
morphine)
• Terminal stage debility
Note: It is important to seek expert advice before
initiating a syringe driver.
*Details are available at the web site: http://www.elmmb.nhs.uk/palliative-care/
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™™ Provide physical treatment as necessary, e.g.
pleural tap, paracenthesis and nerve block.
™™ Provide complementary conservative
therapy e.g. massage, physiotherapy,
occupational therapy, dieting advice,
relaxation therapy
™™ Close follow-up and review regularly.
Support of Family and Carers
Family caregivers, who are patients’ relatives
and friends (commonly called as ‘carers’)
are actively involved in caring for their loved
ones and play a significant and arguably
most important role in enabling patients
to make choices about their place of care
during advanced disease and in the terminal
phase. Family carers invest a great deal of
their time on emotional and social support
as well as on assisting in the provision of
personal care and offer domestic support
like home maintenance, meal delivery and
transportation. Their involvement provides
warmth and helps to cope with their physical,
psychological and emotional needs. It also
provides an opportunity to say ‘goodbye’.
Support after the Death
Physicians must always show sympathy and
listen to relatives patiently and be prepared to
go through what has happened again. Avoid
harsh and insensitive words. Relatives may
feel utterly sad, numb and be thankful that
their relative’s suffering is over. Remember to
acknowledge that all such feelings are normal.
Explain about the administrative procedures
like obtaining death certificate, registering
death and funeral arrangements. Bereaved
family members highly value a physician
condolence telephone call, letter, or visit, as
well as attendance at the patient’s funeral.
This solace is found to improve bereavement
outcome. Encourage the family to be in touch
with the primary care team who knows the
 Chapter 31: Palliative Care: Principles 313
family for several years and be able to offer
ongoing support.
Dams Cicely Saunders, a pioneer in the
modern palliative care movement once said,
“How people die remains in the memories
of those who live on”. Therefore, physicians
have a special responsibility and fundamental
opportunity to pay special attention to grief
and bereavement following death of a loved
one. Thus, in caring well for family caregivers
at the end of life, physicians not only improve
the experiences of patients and family, but also
find greater substance and meaning in their
own work.
The Limits of Care at the
End of Life30
The care at the end of life is not passive but an
active and potentially exhausting act. Many
physicians find it the most rewarding aspect of
their practice. However, they must recognize
and respect their own limitation and attend
to their own needs in order to avoid being
overburdened, distressed, or emotionally
depleted. Physicians should learn that care
of patients at the end of life is not solely their
responsibility. It is a multidisciplinary care
involving physicians, physical and occupational
therapists, nurses, psychologists, dieticians,
social workers and volunteers, who co-ordinate
their skills and support one another.
Summary of Tasks for the Patients
in the Dying Phase20
Physical (Comfort) Measures
™™ Assess current medication, discontinue
non-essentials
™™ Discontinue inappropriate interventions
(e.g. lab tests, IV Fluids, invasive monitors)
™™ Document DNAR, i.e. Do not attempt
resuscitation
™™ Administer subcutaneous drugs as per the
protocol (pain, agitation, nausea, vomiting,
respiratory tract secretions).
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Psychological Issues
™™ Assess patients’ ability to communicate
clearly in native language
™™ Ascertain patient has the insight and status
of the illness
™™ Establish communication with patients’
family and social circle of friends,
guardians, and well-wishers—both young
and old.
Religious and Spiritual Support
™™ Assess religious and spiritual needs with
patient and family.
Communication with Family and
Family Doctor
™™ Identify how family and other people
involved are to be informed of patient’s
impending death
™™ Provide necessary hospital death pro­
cedure information
™™ Keep updating the family physician about
patient’s condition.
Conspiracy of Silence
Although, respect for individual and cultural
differences in attitudes toward death and dying
is considered an essential aspect of appropriate
care for terminally ill patients, physicians and
healthcare workers often find caring family
members desiring not to disclose the diagnosis
to the patients. Statements such as, “We do not
want my father to know the diagnosis because
we are sure he will not be able to take it and will
develop depression with suicidal tendency”,
are common requests from patient’s family
members. Frequently, the patient’s ability to
know the truth is underestimated. The patient
may already suspect the truth, but also tries to
spare the family members the pain of knowing
that the diagnosis and prognosis are already
known to him/her. Thus, a ‘conspiracy of
silence’ is developed to protect the patient.
Further, conspiracy of silence is prevalent in our
 314  Section 7: Palliation and Bereavement
society because families are usually concerned
about the coping needs of the patients. Also,
the economic and cost-effective outcomes,
although well meant, results in a heightened
state of fear, anxiety and confusion—not
one of calm and equanimity. Ambiguous or
deliberately misleading information may afford
short-term benefits while things continue to go
well, but denies individuals and their families’
opportunities to reorganize and adapt their lives
toward the attainment of more achievable goals,
realistic hopes, and aspirations.
Therefore, in recent years, there has been a
trend toward candor and straightforwardness
with patients. Truth disclosure is fast becoming
the accepted pattern. In general, the physician
shall disclose the diagnosis to the patient and
with due care, circumspection and responsibility
inform the most likely prognosis. The physician
shall also inform the closest relatives or
whomever the patient designates. It might be
sensible not to immediately communicate a very
poor prognosis, for the benefit of the patient,
although this approach should be considered
exceptional in order to safeguard the right of the
patient to decide about his future. Another policy
that can be followed for solving family-related
barriers to truthfulness in cases of terminal
illness is that health professionals communicate
with families first and discuss the possible
emotional reactions from patients, give patients
enough time to reflect on their sicknesses
and discuss further what patients have been
told, and then disclose information, based on
patients’ expectations and support them. Thus
the consensus is - at a time when a terminally ill
patient most needs closeness with loved ones, a
lie may serve to push them apart.31,32
Conclusion
Palliative care is an approach that improves
the quality of life of patients and their families
facing the problem associated with life-
threatening illness.
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Effective palliative care requires a broad
multidisciplinary approach that includes the
family and makes use of available community
resources.
The palliative team:
™™ Provides relief from pain and other
uncomfortable symptoms
™™ Assists in making difficult medical decisions
™™ Coordinates care with other doctors and
helps navigate the often-complex health
care system
™™ Guides in making a plan for living well, based
on your needs, concerns and goals for care
™™ Provides emotional and spiritual support
and guidance
End-of-life concerns, such as where the
patient may wish to die, decisions regarding
futile treatment and/or life sustaining
measures and organ donation should be
addressed openly and honestly, with support
offered according to the patient’s and family’s
cultural and religious values.
References
1. American Geriatrics Society (AGS) Position
Statement. The Care of Dying Patients Ags
Ethics Committee. Last updated 2007.
2. Billings JA. Palliative care Recent Concepts.
BMJ, 2000;321:555–8.
3. Field MJ, et al – Committee on care at the end of
life. Institute of Medicine. Approaching death:
Improving care at the end of life. Washington
DC: National Academy Press, 1997.
4. Desbiens NA, et al. SUPPORT investigators. The
symptom burden of seriously ill hospitalized
patients. J Pain Symp. Manag, 1999;17:225–48.
5. Anne Simmonds, Director, Chaplaincy
Services, Decision-Making by Default :
Experiences of Physicians and Nurses with
Dying Patients in Intensive Care. J of the art
and science of medicine, vol 12, no.4.
6. Christakis, et al. Extent & Determination of
error in doctor’s prognosis in terminally ill
patients: prospective cohort study BMJ, 2002;
320:469–73.
 Chapter 31: Palliative Care: Principles 315
7. WHO web site: http://www.who.int/hiv/
topics/palliative/PalliativeCare/en/
8. Temel JS, et al. Early palliative care for patients
with metastatic non-small-cell lung cancer. N
Engl J Med, 2010;363(8):733–42. doi: 10.1056/
NEJMoa1000678.[PMID:20818875: Free Article].
9. Mitchell GK . How well do general practitioners
deliver palliative care? A systematic review.
Palliat Med, 2002;16(6):457–64. [PMID:
12465692: Abstract].
10. Murray SA, et al. Internationally, it is time to
bridge the gap between primary and secondary
healthcare services for the dying. Ann Acad
Med Singapore, 2008;37(2):142–4. [PMID:
18327351: Abstract].
11. The Royal College of Pediatrics and Child
Health. A guide to the development of children’s
palliative care services. London: RCPCH, 1997.
12. Jennings PD. Providing pediatric palliative
care through a pediatric supportive care team.
Pediatr Nurs, 2005;31(3):195–200 [PMID:
16060583: Abstract].
13. Vickers J, et al. Place and provision of palliative
care for children with progressive cancer:
a study by the Paediatric Oncology Nurses’
Forum/United Kingdom Children’s Cancer
Study Group Palliative Care Working Group.
J Clin Oncol, 2007;25(28):4472–6. [PMID:
17906208: Free full text].
14. Menon BS, et al. Pediatric cancer deaths:
curative or palliative? J Palliat Med, 2008;
11(10):1301–3. [PMID: 9115887: Abstract].
15. Muenzer J et al. Mucopolysaccharidosis I: manage­
ment and treatment guidelines. Pediatrics,
2009;123(1):19–29.[PMID: 19117856: Abstract].
16. Rahow MW, et al. Pallitive care & pain
management. In: Stephen J, et al (Eds) Current
Med Diag & Treat, 2009.pp. 83.
17. WHO Expert Committee. Cancer pain relief and
palliative care. No. 804. Geneva: World Health
Organization Technical Report Series, 1990.
18. We b s i t e : h t t p : / / w w w . d h. g ov. u k / e n /
Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/
DH_4071083. (Accessed on 19-01-20090).
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19. Rabow MW, et al. Palliative care & Pain
management. In: McPhee SJ et al (Eds) Current
Med Diag & Treat, 2009.pp.73.
20. Benjamin L. Pain management in sickle
cell disease: palliative care begins at birth?
Hematology Am Soc Hematol Educ Program.
2008;2008:466–74. [PMID: 19074128: Free full
text].
21. A New Vision Of Palliative Care NHWG;
Adapted from the Canadian Palliative Care
Association & Frank Ferris, MD
22. WHO Palliative care web site: http://www.who.
int/cancer/palliative/en/
23. Working Party Report. Mud & Stars. Oxford:
Sobell Publications, 1991.
24. Paul Glare, et al. A systematic review of
physicians’ survival predictions in terminally ill
cancer patients BMJ, 2003;327:195 (Published
24 July 2003)
25. Crooks V, et al. The use of the Karnofsky
Performance Scale in determining outcomes
and risk in geriatric outpatients. J Gerontol,
1991;46:M139–M144.
26. Oxford Textbook of Palliative Medicine, Oxford
University Press, 1993;109.
27. Schag CC, et al. Karnofsky performance status
revisited: Reliability, validity, and guidelines. J
Clin Oncology, 1984;2:187–93.
28. Oken MM, et al. Toxicity And Response Criteria
Of The Eastern Cooperative Oncology Group.
Am J Clin Oncol, 1982;5:649–55.
29. Ellershaw J, et al. Care of the dying patient: the
last hours or days of life. BMJ, 2003;326:30–34.
30. Rabow MW, et al. Care at the End of Life. In:
Tierney LM Jr, et al (Eds); Current Med Diag &
Treat, 2001.pp.111.
31. Hu WY, et al. Solving family-related barriers
to truthfulness in cases of terminal cancer in
Taiwan. A professional perspective. Cancer Nurs,
2002;25(6):486–92. [PMID: 12464841: Abstract].
32. Fallowfield LJ, Truth may hurt but deceit hurts
more: communication in palliative care. Palliat
Med, 2002;16(4):297–303. [PMID: 12132542:
Abstract].
 32 PALLIATIVE HOME CARE

“Palliative care at home embraces what is most noble in medicine: sometimes curing, always relieving,
supporting right to the end.”
Gomas 1993
“Let’s not assume people need to be moved up and down a continuum. The less we move people the easier
it will be for them to develop relationships and support systems that will help them maintain recovery. If
there is any moving to do, let’s move the staff instead”.
Ashcraft L et al. Home is where recovery begins. [PMID: 18561620].

Caring at Home—Some including, e.g. nurses, general practitioners,

Considerations social workers, pastoral care workers, volunteers,
working alongside specialists and other
People with serious life limiting illness such community organizations that manage day-
as cardiac disease, respiratory disease, kidney to-day care and support. However, providing
failure, Alzheimer’s, AIDS, neurodegenerative such homogeneous care at home is a great
disorders and other age related problems need commitment as well as a challenge for the family
good palliative care, which is an approach that members and other supporters because caring
improves the quality of life of patients and their at home is a 24 hour a day, 7 day a week job.
families facing problems associated with life- Palliative home care may also get hampered
threatening illness. This is accomplished by for want of good communication with the
way of prevention and relief of suffering, early patient and family, availability and willingness
identification and impeccable assessment of family to care for the patient at home, team
and treatment of pain and other problems, work by all concerned in such care, necessary
physical, psychosocial and spiritual. resources, and taxing finances. Therefore, the
Providing such care, in an institutional family members and other informal supporters
set up such as hospital or hospice*, involving (e.g. family relatives, friends, neighbors, pastors,
multidisciplinary team is much easier due to the and community volunteers) need to consider
infrastructure and immediate support available, resources carefully and plan ahead (Table 32.1).
*Hospice is an institution that provides a centralised program of palliative and supportive services to dying
persons and their families, in the form of physical, psychological, social, and spiritual care; such services
are provided by an interdisciplinary team of professionals and volunteers who are available at home and
in specialised inpatient settings.
Palliative care is not the same as hospice care. Palliative care may be provided at any time during a person’s
illness, even from the time of diagnosis. And, it may be given at the same time as curative treatment. Hospice
care always provides palliative care. However, it is focused on terminally ill patients-people who no longer
seek treatments to cure them and who are expected to live for about six months or less.

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Table 32.1  Can you take care of a terminally ill person
at home?
Some questions to ask yourself when deciding to
undertake end-of-life care of a loved one:
• Has the patient set forth his/her preferences for
end-of-life care that include remaining at home?
• Is qualified, dependable support available to
ensure 24-hour care?
• Will your home accommodate a hospital bed,
wheelchair, and bedside commode?
• Are transportation services available to meet daily
needs and emergencies?
• Is professional medical help accessible for routine
and emergency care?
• Are you able to lift, turn, and move your loved
one?
• Can you meet your other family and work
responsibilities as well as your loved one’s needs?
• Are you emotionally prepared to care for your
bed-ridden loved one?
Adapted from: The Loss of Self: A Family Resource for the
Care of Alzheimer’s Disease, Donna Cohen, PhD, and Carl
Eisdorfer, PhD.
Chapter 32: Palliative Home Care 317
Table 32.2  Dignified death**
“A model of dying with dignity would include at least
the following elements:
• Dying without a frantic technical fuss and bother
to squeeze out a few more moments or hours of
biological life, when the important thing is to live
out one’s last moments as fully, consciously, and
courageously as possible
• Dying without that twisting, racking pain that
totally ties up one’s consciousness and leaves
one free for nothing and for no-one else
• Dying in surroundings that are worthy of a
human being who is about to live what should be
one’s “Finest hour”. The environment of a dying
patient should clearly say: the technical drama
of medicine has receded to the background to
give way to the central human drama of a unique
human being “wrestling with his God”
• Dying in the presence of people who know how
to drop the professional role mask and relate to
others simply and richly as a human being.
**David Barnard. Palliative Care: Whole-Person Care of the
Dying Patient. In: World Anesthesia Online. 1998;16(2):1.

Definition* maintenance, social adaptation and integration,

and support for the family caregiver.
WHO defines palliative home care as:1
Home care services help people with
“The provision of health services by
a frailty or with acute, chronic, palliative
formal and informal caregivers in the home
or rehabilitative healthcare needs to
in order to promote, restore and maintain a
independently live in their community. While
person’s maximum level of comfort, function
the majority of clients receiving home care are
and health, including care toward a dignified
seniors aged 65 years and over, home care is
death” (Table 32.2).
provided to individuals of all ages.”
The Canadian Home Care Association
defines Home Care as:2
Home Care: Issues in Developing
“… an array of services, provided in the home
and community setting, that encompass health Countries—is There a Need?
promotion and teaching, curative intervention, Western countries have ‘model palliative care
end-of-life care, rehabilitation, support and teams’** which practice multidisciplinary

*Home care services can be classified into : geriatric care(e.g. instability, disability, incontinence, dementia);
convalescent care (e.g. post-operative); rehabilitative care (e.g. stroke, fracture); maintenance care (i.e. to
prevent deterioration, complications, or to improve clinical outcome); palliative care (i.e. to patients whose
disease is not responsive to curative treatment with poor clinical prognosis expected, their life expectancy is
usually not more than six months); and psychiatric care (e.g. severe dementia, agoraphobia).
**Members of a palliative care team may include professionals from nursing, medicine, social work,
chaplaincy, nutrition, rehabilitation, pharmacy as well as other disciplines. Trained volunteers are
sometimes part of palliative care teams as well. Team leadership, collaboration, coordination and
communication are key elements for effective integration of these disciplines and services.

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 318  Section 7: Palliation and Bereavement
approach and also have a very efficient ‘mobile and pain relief are essential to provide good
palliative team’* network.3-6 Therefore, it is quality life for these patients.12
possible to achieve good symptom control and With respect to HIV/AIDS, worldwide, an
give efficient palliative care at patient’s home estimated 34 million people were living with
because physicians and nurses are trained HIV at the end of 2011. Worldwide, 2.5 million
in palliative care in those countries. Besides, [2.2 million–2.8 million] people became newly
‘Macmillan Cancer Support’ project offers infected with HIV in 2011.13
supportive care to not only patients who live With respect to Asian countries, the rate of
with cancer, but also help carers, families, and HIV transmission slowing down; however, an
communities, supporting them every step of estimated 3, 60,000 adults were newly infected
the way.7 with HIV in Asia in 2011, i.e. at least 1,000
However, in developing countries, new infections among adults continue to be
the numbers of palliative care centers are reported in the continent every day in 2011.14
few,** health delivery systems are often Although India has registered 57% reduction
patchy and deficient, medications for pain in new HIV infections during last decade, India
management are not widely available and has the third largest HIV/AIDS epidemic in the
cultural considerations limit opportunities to world. According to the 2008 Government of
face advanced illness and symptom control India national estimates, there are 2.27 million
in terminal illness. 8-10 There are few pain people living with HIV/AIDS. Despite having
relief units, but it is important to realize that a low prevalence rate (estimated adult HIV
palliative care is much more than pain relief— prevalence is only 0.29% of the population),
it’s an investment in whole personal care. with a high population rate and low economic
The magnitude of cancer problem in the growth, an epidemic would take a huge toll in
Indian sub-continent is increasing due to high the region—even small increase in the HIV/AIDS
rates of smoking, tobacco use, occupational rates in India could have global ramifications.
risks, unhygienic residential living conditions, Existing preventive efforts, although improving,
unhealthy life-style factors and inadequate are often insufficiently comprehensive or
medical facilities. The prevalence of cancer inadequately tailored to local epidemics. Further,
in India is estimated to be around 2.5 million, the cost of Highly Active Antiretroviral Therapy,
with approximately 8, 00,000 new cases and although at reduced cost, is a major limiting
5, 50,000 cancer related deaths per annum, factor in continuing drugs, which hastens
and more than 75% of deaths occur at home.11 the emergence of resistance by not adhering
Further, more than 75% of cancers in India to prescribed therapies. Therefore, due to
present in advanced stages and palliative care lack*** or high cost of anti-retroviral therapy, or
*Mobile palliative team covers the whole province; the teams consist of medical doctors, care staff and
social workers who collaborate with the family doctors and the professional and informal carers. Such a
team can be called in by all those concerned, the patients, the relatives, the family doctors, etc., and the
service is free of charge: the costs are covered by the State Health Fund.
**India has witnessed hospices like Shanti Avedhana (Mumbai); Amrita Kripa Sagar Cancer Hospice
(Mumbai); AIMS (Kochi); Cipla (Pune); Pain and Palliative Clinic , Calicut – now a WHO recognized
model of delivery of palliative care for South-east Asia, among a couple of others coming up to meet the
challenge of providing care for the no-cure diseases.
***Over 7 million other people who are eligible for ART still have no access to treatment.
Source: WHO, 10 facts on HIV/AIDS. Nov. 2012. Web site:
http://www.who.int/features/factfiles/hiv/en/index.html (Accessed on 26-06-2013).

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development of anti-retroviral drug resistance,
these patients will die prematurely. It is estimated
that about 1.48 lakh people died of AIDS related
causes in 2011 in India.15,16
Further, as a result of growing elderly
population due to increased life expectancy,
there is large number of elderly patients with
end stage chronic diseases needing palliate
care. This elderly population with serious
chronic diseases exceedingly needs help at
the end of life from their potential family care
givers. However, the society is changing with
one of the most significant alterations being
the disintegration of the joint family and the
rise of nuclear and extended family system.
The break-up of the traditional large family
group and other sociological trends, such as
urbanization, complicate the situation.
Family groups are often intact in rural
areas, taking care of the older or disabled family
members. In the urban communities, factors
such as small family units, limited living space
and the younger generations often moving
away from their families because of work
commitments, it’s an onerous task for such a
family to take care of the older or disabled family
members. The WHO document for “Home care
in Europe: The solid facts” states: “urbanization
and the break-up of the traditional large family
group will lead to gaps in the care of older or
disabled family members. These changes in
needs and social structure require a different
approach to policy and services in the health
and social sectors; a disease-oriented approach
alone is no longer appropriate. Evidence suggests
that disabled and older people tend not to
want institutional care, and families and other
informal carers prefer strongly to continue to care
for their dependent family members in a friendly
environment such as their own homes and local
communities.”17
Demoralizing Syndrome
As a result of increased life expectancy, there
is large number of elderly patients with end
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Chapter 32: Palliative Home Care 319
stage chronic diseases needing palliate care.
When chronic life-limiting or terminal
illness advances, the individual’s fear of loss
of dignity and perception of being a burden on
others may evolve a desire to die or to commit
suicide. Such feeling of despair, isolation,
hopelessness, loss of meaning and existential
distress, is called ‘demoralizing syndrome’
(Table 32.3), and commonly associated with
chronic medical illness
It has been argued that as demoralizing
syndrome being diagnosed a specific
psychiatric condition in the terminal phase of
a terminal illness, there will be an opportunity
for patients to assist in overcoming these
negative emotions. Patients and their families
can be regularly supported, comforted, and
indeed palliated by a range of appropriate
psycho-social approaches.18
Home—the Preferred Choice19-21
Recent Cochrane Database has documented
extensive evidence showing that well over 50%
of people prefer to be cared for and to die at
home provided circumstances allow choice.
This justifies providing home palliative care
for patients who wish to die at home.22
In another study, 23 nearly 90% of the
subjects preferred to die at home. Quality of
life, availability and ability of family caregivers,
concerns of being a burden to others, long-
standing relationships with healthcare
providers, and quality of healthcare were
the major considerations in decision making
Table 32.3  Demoralization syndrome: Diagnostic
criteria
1. S ymptoms of existential distress, such as
meaninglessness, pointlessness, hopelessness.
2. Sense of pessimism, “stuckness”, helplessness,
loss of motivation to cope differently
3. Associated social isolation, alienation or lack of
support
4. Phenomena persist over more than 2 weeks.
*1, 2 and 4 are essential for the diagnosis.
Source: Sahoo S. Demoralization syndrome—A
Conceptualization. Orissa Journal Psychiatry, September 2009.
 320  Section 7: Palliation and Bereavement
regarding the place of death. Terminally ill
patients with cancer acknowledged dying
at their preferred place of death as highly
important.
A chronic illness often leaves the family
and the patient depleted of their financial
resources and any further hospitalization adds
to the burden. On the contrary, homebound
care reduces admission, length of hospital
stays, re-admissions, intensive care unit
admissions, and inappropriate diagnostics
and interventions. In-home palliative care
significantly increased patient satisfaction
while reducing use of medical services and
costs of medical care at the end of life.24
A matter of vital importance is the family
bondage which is a strong component of
many societies universally. Although social
and cultural life styles are changing, members
of the family are available and willing to
provide care. This is a major strength in
family dynamics and every effort must be
made to encourage support and harness these
resources, so that the quality of life toward the
end of life can be maximized by home care—
when someone with an advanced illness gets
home palliative care, their chances of dying at
home more than double.25
A key component of palliative care is home-
based care, which in many resource-limited
settings is the only way to deliver care to the
patient. Further, medical facilities often lack
trained personnel and basic medical supplies
and medications. In these settings, palliative
care programmes that focus attention on
integrated community and home-based
care, i.e. a sustainable approach to prevent
the need for unnecessary acute or long-term
institutionalization and to maintain people
in their homes and communities as long as
possible, is the most efficient and cost-effective
approach to healthcare delivery.26
The practical advantages of home care for
patients with advanced or terminal care are
symmetrized in Table 32.4.
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Table 32.4  Home care: Advantages
• Facilitates psychological transition to palliative
phase from curative phase
• Enhances patient-centered care, privacy, and
autonomy in their own environment
• Provides care for the patient and their family
as a unit
• Patient spends maximum with family members
• Provides maximum symptom control under closer
observation
• S u p p o r t s p a t i e n t a n d f a m i l y m e m b e r s
psychologically and spiritually within their own
environment
• Endeavors to provide overall maximum quality
of life till end
Involvement of Family Physician27
With the ever-increasing burden of palliative
care on one side and limited resources available
on the other, the network of palliative care
needs to be extended from few regional centers
to primary care centers in a phased manner
with adequate training and availability of basic
necessities. In this regard, the important role
of the family physicians as a result of their
intimate partnership with the aiding patients
and their family cannot be over emphasized.
By virtue of their lifelong relationship
with patients most family physicians practice
some form of palliative care. Family physicians
and the primary care team manage 90% of a
patient’s palliative care needs. In most cares,
the patients are ambulatory and seen in
doctor’s clinics or in their own homes or other
community settings. When family physicians
provide palliative care, they bring skills that
are unique to their broad based practice
philosophy. Family physicians provide person-
centered, continuous, comprehensive care
that is accessible and available at the time of
need. A definition proposed by Royal College
General Practitioners’ Cancer Working Group
of Primary Palliative Care states that:
“General practitioners, within the context
of primary care, provide palliative care which
incorporates the palliative care approach and
in addition uses those skills in consultation,

diagnosis, treatment and management that
are peculiar to general practice. These will
include a holistic approach, advocacy, and
continuity of care and enhanced symptom
control as befits the GP’s experience and
training. This would be progressed to that
point where the expertise inherent in specialist
palliative care would be invited to contribute
the patient’s overall care. GPs usually retain
overall responsibility for patient’s care while
the patients remain in their own home or
similar community base”.
How to Get Started and
Keep Going
There are many Institutes for Palliative Medicine
offering accredited palliative medicine
fellowship training. Fellows who complete the
program gain experience in a variety of settings,
whether in a hospice inpatient setting, at a
patient’s home, or in a consultative capacity at
a hospital. This experience prepares the fellow
to work in a leadership role in palliative care,
education or research.
However, with proper planning and
support from colleagues, hospital facilities
and community support, a family physician
can provide homebound palliative care with
emphasis on the following essentials:
™™ Core and support team : Identify a
‘core team’ for home care, consisting of
physicians, ‘palliative care specialists nurses’
(PCSNs), social workers, therapist (physio/
occupational), counselors, psychiatrist,
religious heads, transportation, and drivers.
™™ This core team may be further supported by
a ‘support team’ consisting of volunteers,
dietician, pharmacist, public relation
officer, and family members.
™™ Commonly, the PCSNs act as case
managers and provide holistic care to
their patients after an initial assessment of
home set-up and family dynamics. Based
on the patient’s condition, needs, and
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Chapter 32: Palliative Home Care 321
expectations of the services, the PCSNs
formulate a care plan. They conduct
preliminary interview with patients and
their families, establish rapport, assess
pain and other symptoms, administer
drugs and nursing care, educate patients
and their family members, and act as a
liaison and case managers for various
services. Physicians and other healthcare
professionals also visit patients when
indicated.
™™ Nursing services: The availability of
nursing services varies widely. In most
cases daytime nursing care can be provided
without much difficulty; but night shift
services are limited. The choice may
depend on the complexity of care and the
need for the drugs to be administered.
™™ Communication: For effective coordination
of professionals, optimum system of
communication is essential. A clear
communication of the management plan,
appropriate drugs, their dosage, and
routs of their administration, and regular
monitoring of compliance, and the effect
of treatment are essential to good symptom
control at home. In recent years, wide
varieties of methods have been used to
improve communication between the
hospital, hospice, and primary care centers
in palliative care. The most successful are:
ƒƒ A patient held record card
ƒƒ Dedicated telephone slots allocated for
direct contact
ƒƒ Fax and E-mail facilities
ƒƒ Internet chat rooms for patients and
professionals.
™™ Teamwork: It is important to define the
role of each team member and ensure
their appropriate training, when needed
they should also be prepared to overlap
in role function. Training of the family to
provide effective care at home is important.
Family physician must maintain overall
 322  Section 7: Palliation and Bereavement
responsibilities for the medical care of the
patient at home.
™™ The core and the support team should
meet regularly for discussion of patient
related issues, general issues, and for
training of team members.
Clinical Issues
Symptom control is by far the most important
area in palliative home care management of
the patient.
Controlling Pain
™™ Untreated pain takes a major toll through
its direct effect on the patient and the fear
it instills in both the patient and the family
members. The family physician, therefore,
needs to be proactive in alleviating it.
Providing a patient with quality care
to the end of life requires knowledge
of new information and techniques for
symptom control. Virtually all end of life
interventions use agents and techniques
with which family physicians are familiar,
although the dosages and delivery systems
are sometimes different. That these skills
are obtainable by family physicians is
addressed in a study in a community
based hospice patients.28 Family physicians
can achieve successful pain relief in
nearly 90% of dying patients by following
recommended guidelines on the use of
analgesics, including narcotics.29
™™ Morphine in still the mainstay of pain control,
along with a number of related opiates. The
dosage, various routes of administration, and
side-effects of morphine should be familiar
to the physicians and nursing staff (Table
32.5). Co-analgesic is often needed for the
various forms of neurological, bone, and
visceral pain. Fears of respiratory depression
and dependence are unfounded in this group
of patients. Confusion may be short lived.
Nausea and constipation can be controlled
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Table 32.5  Basic principles of introducing oral
morphine
• Give morphine orally—tablets10 mg, to 20 mg
4th hourly, or in aqueous solution, e.g. 2 mg/ml).
Lower doses may be needed in elderly people
and those with renal impairment
• Use rescue dose in addition, if pain returns
between the regular doses
• Titrate dose upward, e.g. from 5–10 mg, 10–15
mg, or 20–30 mg, if the pain is not at least 90%
relieved during the first 24 hours
• With ordinary tablets or solution, a double
bedtime dose usually enables a patient to go
through the night without walking in pain
• Treat side-effects with a laxative and antiemetic
• When pain is controlled, convert to a slow-
release form of morphine (30 mg/12hours), with
added immediate-release preparation available
for rescue pain
• Only one-third of patients require more than
30 mg morphine every 4 hours, or more
than 100 mg every 12 hours of slow release
morphine. Only a few patients require 100
mg every 4 hours, or 600 mg slow release
morphine every 12 hours
by adjuvant antiemetics and laxatives. There
are many pain control charts and assessment
tools,30 which are very useful for determining
changes in patient’s progress, particularly
when verbal communication becomes
difficult.
™™ Though in developed countries ‘model
palliative care teams’ provide high
technological home care, including
intravenous infusions, these are not
practicable in many peripheral and home
care set ups. Such patients may require
hospitalization only for parenteral therapy.
To overcome such problems, exploration
of other routes of drug administration
will result in better symptom control at
home and also cost effective. Transdermal
fentanyl patches, sublingual lorazepam,
sublingual nifedipine are some examples
of alternative routes of drug therapy.
Some drugs are available in rectal forms
in different parts of the world, e.g.
paracetamol, aspirin, NSAIDs (naproxen,
ibuprofen, diclofenac, indomethacin),
 Chapter 32: Palliative Home Care 323

Opioids (morphine, hydromorphin, codine, ™™ Anticipate the kind of emergency a patient is

methadone), diazepam, chlorpromazine, likely to face in advance, e.g. in a patient with
phenobarbital, atropine, ondansetron, vertebral metastasis who is likely to develop
imipramine, etc. Rectally administered spinal cord compression—draw an agreed
medications require minimal family plan to be followed methodically, rather than
education and expense as compared with struggle with arrangements at odd hours,
parenteral infusions. e.g. who needs to be contacted, whether the
patient is to be hospitalized or stay at home
Controlling other Symptoms and what life-prolonging measures would be
Morphine is very useful for controlling appropriate. Someone should always remain
nonpain symptoms such as breathlessness, with the patient.
agitation, pruritus and diarrhea. Various ™™ Ascertain emergency drugs are available
other drugs, e.g. tricyclic antidepressants, such as injection morphine, midazolam
anticonvulsants, corticosteroids, anxiolytics by subcutaneous route, and clonazepam
and antiemitics should be used as per the tablets by sublingual route. In certain
needs and guidelines.* situations, essential support equipment,
like oxygen cylinders, suction apparatus
Copying with Emergencies can be made available which trained family
members can use.
In the course of palliative care a variety of ™™ Be aware of patient’s wishes in the event
medical emergencies arise (Table 32.6). The of emergency, e.g. resuscitative measures
most common ones are hemorrhage, fractures, and living will.
intestinal obstruction, spinal cord compression, ™™ Be aware of family/carer wishes, e.g. to be
convulsions, hypercalcemia, superior vena with the patient till the end, to perform
caval obstruction and sudden worsening of religious formalities in the dying phase.
dyspnoea. Nearly all of these need specialist ™™ Always arrange follow-up for the family to
intervention, but not all require admission to minimize distress, panic, and guilt feelings.
hospital or hospice. The following measures
help to minimize patient and family distress and Drug Compliance
enhance care in the event of an emergency:
Although drug compliance of palliative
Table 32.6  Emergencies in palliative care care patients at home has been generally
Not to miss Other emergencies unsatisfactory, much can be achieved by
• Spinal cord • Seizures avoiding polypharmacy, stopping unnecessary
compression • Intestinal obstruction and ineffective drugs, using simple regime,
• Superior vena cava • Obstructive
syndrome nephropathy clear explanation of the use and regular
• Hemorrhage • Cardiac tamponade monitoring of side-effects of the drugs.
• Hypercalcemia • Tumor lysis
• Pathologic fracture
• Drug toxicity/side
• Febrile neutropenia
• Increased
Patient Issues
effects intracranial pressure Personal Care
• SIADH
• Hypoglycemia As patients become increasingly ill, they will
• Extreme anxiety/ need help with different aspects of personal
apprehension
attention like brushing their teeth, bathing,

*Ref. Chapter 31-Palliative care: Principles: Table 31.10

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 324  Section 7: Palliation and Bereavement
shaving, trimming nails and dressing. In
addition they will be required to be moved
periodically in their beds to avoid pressure
sores. Any member of the family, nurse or
volunteer can provide this sort of care at home
with basic training.
Emotional Support
Patients go through different stages of terminal
illness such as denial, anger, depression,
and acceptance. Family, friends, doctors,
and nurses can give emotional support at
such times. However, many times emotional
support might be needed for the family
themselves, in which case services of skilled
counselor should be arranged.
Spiritual Support
On many occasions patients deny any spiritual
faith during their lifetime, but feel its necessity
as they face an impending end. A religious
counselor should be arranged to visit, listen,
and counsel the patient. Due care should be
taken not to advocate a faith other than the
patient’s own.
Nutrition
Good nutrition helps to boost the immure
system of the body which is more important
in terminally ill patients. Unfortunately, eating
is a problem for many terminal patients.
Many drugs can alter the taste of food and
even specific and hitherto favorite foods
become unpalatable. Depression and other
GI problems make it difficult to digest food.
With some clever diet manipulation in its
variety and consistency the family members
can overcome such problems. In selected cases
the help of a dietician will be of immense help.
Medical Supplies and Equipment
Medical equipment, like syringe driver,
nebulizer oxygen cylinders, suction apparatus;
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as also practical utility equipments like
wheelchair, bedpans commode, bath aids,
pressure mattress, walkers can be obtained on
loan for temporary use from charitable trusts
or hospice institutions.
Back up Services
The palliative home care team, however
good its intension and efforts may be, will
not be able to provide every type of service,
equipment or other help to the patient and
family. It is therefore essential to enroll the
services of physicians, palliative consultants,
nurses, legal experts, spiritual services and
medical equipment suppliers who are willing
to come to the rescue in critical situations.
The details of this list, complete in all aspects,
should be made available to all the members
of the core team as well as the family members
of the patient.
Financial and Legal Aids
A non-controversial and reliable legal advisor
can be arranged to assist the patient in
preparing a will, sorting out property matters,
ensuring that insurance policies are complete
in all respects, etc. In some cases patients are
known to express a wish to specify the extent of
life sustaining methods to be used in the event
of their going into coma. Any other important
issue that the patient may not have covered
during such discussions and which may have
important implications for the future of the
family may be brought out by the adviser
without in any way influencing the decisions
of the patient.
Respite Care
Both the patient and the caregiver need to have
a respite—a change of scene from the sickroom
at home for a few hours or even a day or two—in
order to avoid a possible breakdown from sheer
exhaustion. This can be arranged in two ways.

The caregiver may take a break for a specific
duration and another attendant can look after
the patient. Another way is to offer temporary
care as an in-patient in a hospice who is willing
for such a make-shift arrangement. This would
give both the patient and the caregiver the
break they both deserve. This arrangement
requires some advance preparation for
the caregiver to ascertain required care in
the hospice concerned. It must be clearly
understood that there is no sense of guilt at
leaving the patient and also an understanding
that this sort of break is necessary to avoid
physical and mental exhaustion.
Bereavement Support
After the death of the patient, the surviving
relations undergo a variety of emotions. Some
of these are relief, guilt, anger, regret, grief.
There could be a period of denial before the
acceptance of the final parting. All these need
to be acknowledged as real. A bereavement
visit by team members to acknowledge these
emotions, to assist the family to vent their grief,
to come to terms with the reality of the loss of
a loved one, and to assist them to rejoin the
main stream of life again is an essential task
of home palliative care.
Conclusion
The ultimate goal of the management of the
patient at home by the home care team is to
provide uninterrupted care to promote the
quality of life through relief of symptoms—
may they be physical, psychological, social or
spiritual—to patient and family.
Family physicians should view palliative
care as a special area that requires personal
commitment and can give great satisfaction.
All family physicians must become familiar
with the science and art of palliative care and
use this care aggressively to help patients and
their families have the best life possible to the
very end.
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Chapter 32: Palliative Home Care 325
References
1. Home based care and long term care. Home
care issues and evidence. WHO 1999.
2. Canadian Home Care Association. Home Care:
Meeting the Needs of an Aging Population (Sept
2008). Web site: http://www.homecarestudy.
com/overview/index.html#def. (Accessed on
19-01-2009).
3. Cox Ivan G. Palliative care. Medicine Update,
2000;1606–10.
4. Web sites: http://www.macmillan.org.uk/
Home.aspx;
5. Geriatrics, Palliative Care and Interprofessional
Te a mw o rk Cu r r i c u l u m, Mo d u l e # 2 :
Interdisciplinary Teamwork. Web site :
http://www.nynj.va.gov/docs/Module02.pdf
(Accessed on 26-06-2013)
6. Mobile Palliative Teams (MPTs) web site:
http://interlinks.euro.centre.org/model/
example/MobilePalliativeTeams (Accessed on
26-06-2013).
7. Web site: http://www.macmillan.org.uk/
Home.aspx (Accessed on 26-06-13).
8. Maddocks I. Palliative care education in the
developing countries. J Pain Palliat Care
Pharmacother. 2003;17(3-4):211–21.[PMID:
15022964: Abstract].
9. Webster R, et al. Palliative care: a public health
priority in developing countries. J Public
Health Policy, 2007;28(1):28–39. [PMID:
17363933: Abstract].
10. Rajagopal MR, et al. Palliative care in India:
successes and limitations. J Pain Palliat Care
Pharmacother, 2003;17(3-4):121–8; [PMID:
15022956: Abstract].
11. Imran Ali, et al. Cancer Scenario in India with
Future Perspectives. Cancer Therapy. 2011;8:
56–70.
Web site : http://www.iarc.fr/en/media-
centre/pr/2012/pdfs/pr210_E.pdf
12. Cherian Varghese. Cancer prevention and
control in India. Web site: http://www.
rcfcare.org/admin/articles/doc/pg56to67.pdf
(Accessed on 25-06-2013)
13. The global fund, fighting aids. Web Site: http://
www.theglobalfund.org/en/about/diseases/
hivaids/
 326  Section 7: Palliation and Bereavement
14. New HIV cases decline by half in India: UN
report: In DNA news, Jul 19, 2012
http://www.dnaindia.com/india/1717217/
report-new-hiv-cases-decline-by-half-in-
india-un-report (Accessed on 25-06-2013).
15. Press Information Bureau, Government of
India, Ministry of Health and Family Welfare.
30-November-2012. Web site:
http://pib.nic.in/newsite/PrintRelease.
aspx?relid=89785 (Accessed on 25-06-2013).
16. HIV/AIDS in India, World Bank, July 10, 2012.
Web site:
htt p : / / w w w . w o r l d b a n k. o rg / e n / n e w s /
feature/2012/07/10/hiv-aids-india (Accessed
on 25-06-2013).
17. WHO 2008, Europe. Home carein Europe:The
solid facts. Web site:
http://www.euro.who.int/__data/assets/
pdf_file/0005/96467/E91884.pdf (Accessed
25-06-2013)
18. Julia Anaf. Demoralisation Syndrome and the
end of life. The World Federation of right to die
societie. August 21, 1970. Web site
h t t p : / / w w w . w o r l d r t d . n e t / n e w s /
demoralisation-syndrome-and-end-life
(Accessed on 27-06-2013).
19. Brumley R, et al. Increased satisfaction with
care and lower costs: results of a randomized
trial of in-home palliative care. J Am Geriatr
Soc, 2007;55(7):993–1000. [PMID: 17608870:
Abstract].
20. Brumley RD, et al. Effectiveness of a home-
based palliative care program for end-of-
life. J Palliat Med, 2003;6(5):715–24.[PMID:
14622451: Abstract].
21. Tang ST. When death is imminent: where
terminally ill patients with cancer prefer to
die and why. Cancer Nurs, 2003;26(3):245–5.
[PMID: 12832958: Free full text].
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22. Gomes B, et al. Effectiveness and cost-
effectiveness of home palliative care services
for adults with advanced illness and their
caregivers.Cochrane Database Syst Rev, 2013;
6:CD007760. [Epub ahead of print][PMID:
23744578: Abstract].
23. Tang ST. When death is imminent: where
terminally ill patients with cancer prefer to
die and why. Cancer Nurs, 2003;26(3):245–51.
[PMID: 12832958: Abstract].
24. Brumley R, et al. Increased satisfaction with
care and lower costs: results of a randomized
trial of in-home palliative care. J Am Geriatr
Soc, 2007;55(7):993–1000. [PMID: 17608870:
Abstract].
25. Gomes B, et al. Effectiveness and cost-
effectiveness of home palliative care services
for adults with advanced illness and their
caregivers.Cochrane Database Syst Rev, 2013;
6:CD007760. [Epub ahead of print][PMID:
23744578: Abstract].
26. Home care in Europe. The solid facts.
http://www.euro.who.int/InformationSources/
Publications/Catalogue/20081103_2. (Accessed
on 20-01-09).
27. Marshall D, et al. Enhancing family physician
capacity to deliver quality palliative home care:
an end-of-life, shared-care model. Can Fam
Physician, 2008;54(12):1703–1703.e7.[PMID:
19074714: Abstract].
28. Nowels D, et al. Cancer pain management
in home hospice setting: a comparisons of
primary care and oncology physicians. J
palliative care, 1999;15(3):5–9.
29. Whitecar PS, et al. Managing pain in dying
patients. American Fam Phy, 2000;61:755–64.
30. Macmillan Cancer Relief. Helpful essential
links to palliative care, 3rd edn. London:
Macmillan Cancer Relief, 1999.
 33 FAMILY AND THE
GRIEF PROCESS

“Time alone is not enough to heal the wounds of the heart. There is work involved in grieving.”
Good Grief, Zita Annette Weber, 2001

Introduction relationship and familiarity with the family

The experience of grief wears many faces
for physicians and their patients, colleagues,
individuals and families whose lives are
challenged by change, turmoil, illness, death
or the loss of hopes and dreams.
It is commonplace in the bereavement
literature that ‘unresolved grief’* can lead to
difficulties coping with any losses throughout
life. It inevitably causes great distress, and
can give rise or contribute to the onset
of psychosomatic and prolonged grief
disorders.1-3
Knowledge of the process of grief and how
to help individuals and families cope with
their loss experiences can be an invaluable
asset to family physician—including primary
care providers—who have an established
and its culture and are, therefore, placed in a
better position to manage grieved individual
and family members.
What is Grief?
Grief may be defined as deep and intense
sorrow or distress, it refers more to what is
felt or experienced. Raphael uses the term
‘grief’ to convey: “the emotional response to
loss: the complex amalgam of painful affects
including sadness, anger, helplessness, guilt,
and despair.”4**
Grief is:
™™ The normal response of sorrow and
emotions, thoughts and behaviors that
follow the loss of someone or something
important to you.

*Unresolved grief refers to prolongation of normal grief, or grief that does not go away or interferes with the
person’s ability to take care of daily responsibilities. It is identified by (1) painful response to recall of the
deceased, (2) realization of not having accepted the loss or of not being able to grieve, and (3) unexplained,
recurrent depression.
**The literature uses many terms to indicate reactions to loss, often interchangeably: Bereavement: the state
of loss resulting from death; Grief: the distressing emotional response to any loss; Mourning: the process
of adaptation, which includes cultural and social rituals; Anticipatory grief: the distress that occurs before
an expected loss; Pathological, complicated or prolonged grief: an abnormal emotional response to loss
involving mental and/or physical health morbidity; Disenfranchised grief: hidden grief, i.e. when one is
grieving but you can’t talk about or share your pain with others because it is considered unacceptable
to others. It’s when you’re sad and miserable and the world doesn’t think you should be, either because
you’re not “entitled” or because it isn’t “worth it”, e.g. diverse or separation, abortion, job loss, coping with
chronic illness etc.

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 328  Section 7: Palliation and Bereavement
™™ A typical reaction to death, divorce, illness,
job loss, a move away from family and
friends or any life-changing experience.
™™ A natural part of life. In order to move on,
grieving must take place and one must
grieve the loss and find new purpose and
goals in life.
™™ Very personal—it is different for everyone;
there is no right or wrong way to grieve.
How long it takes to grieve and what that
new purpose or goal will be different for
everyone.
Symptoms of Grief
Healthcare providers will see grief in all
its forms over a wide variety of losses, and
encounter bereaved individuals throughout
their personal and professional lives. The
nature of loss and patient’s reaction to it varies
individually. Every person is unique; hence,
there will be many individual differences in
grief experiences. Most people will experience
common or normal grief and will cope well;
others will experience more severe grief
reactions such as prolonged or complicated
grief and will benefit from treatment.
Although grief responses may differ
from one person to another, there are many
predictable expressions of grief. These
expressions are well documented and occur
on emotional physical, cognitive, behavioral,
social, and spiritual levels (Table 33.1).
Features of Grief
Three main characteristics of normal grief are
observed during the process of grieving. They
include the urge to look back, cry, searches
for what is lost; the conflicting urge to look
forward, explore the world that now emerges;
and discover what can be carried forward from
the past. These features can be groped as:
1. Crying: An urge to cry aloud, search, and if
necessary, fight for the lost person occurs
following permanent separations. They
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Table 33.1  Signs and symptoms of grief
Emotional:
Sadness, fear, anger, guilt, anxiety, loneliness,
helplessness, shock, yearning, relief, numbness
Physical
Nausea, tightness in the chest and throat,
hyperacusis, depersonalization, shortness of breath,
weakness, fatigue, dry mouth, agitation, sighing,
restlessness
Cognitive
Disbelief, confusion, guilt related to the deceased or
the circumstances of death, preoccupation with the
image of the deceased, sense of the presence of
the deceased, hallucinations of the deceased, fear
of the inability to care for oneself, heightened sense
of awareness of the potential for personal death
Behavioral
Sleep and appetite disturbance, dreams of the
deceased, social withdrawal, avoidance of reminders
of the deceased, searching, crying, visiting places
as reminders of the deceased, use of a transitional
object, decreased ability to perform day-to-day tasks,
adopting traits of the deceased
Social
Feelings of withdrawal, isolation, a greater
dependency on others, rejection by others, a
reluctance to ask others for help, change in friends
or in living arrangements, a desire to re-locate or
move, a need to find distractions from the intensity
of grief (to stay busy or to over-commit to activities)
Spiritual
Bargaining with God in an attempt to prevent loss,
feeling angry at God when loss occurs, renewed
or shaken religious beliefs, feelings of being either
blessed or punished,
Source: 1. Worden JW. Grief Counselling and Grief Therapy:
A Handbook for the Mental Health Practitioner. New York, NY:
Springer; 1991.
2. Weissman MM, Markowitz JC, Klerman GL. Comprehensive
Guide to Interpersonal Psychotherapy. New York, NY: Basic
Books; 2000.
may misidentify sights and sounds as
indicating the presence of the dead person,
may experience hypnagogic hallucination
of the dead person during periods of
drowsiness or may dream of reunion.
2. Distraction: The person keeps busy, tries
to avoid situation that evoke grief, suppress
emotion and thoughts about the loss.
3. Grief work: The term ‘grief work’ implies
active and necessary exploration to
 Chapter 33: Family and the Grief Process 329
establish a new identity between the
person’s external and internal worlds.
Over time, grieving starts to lessen, and
the individual begins to see life in a more
positive light again.
A common definition of ‘grief work’ is
summarized by the acronym TEAR:
T = To accept the reality of the loss,
E = Experience the pain of the loss,
A = Adjust to the new environment without the
lost object, and
R = Reinvest in the new reality
Course of Grief5
It is sometimes difficult to discriminate the
course of grieving as there is increasing
awareness of the amount of oscillation
between its stages and the interaction
between its phases varies widely. The way
in which a person will grieve depends on the
personality of the grieving individual and his/
her relationship with the person who died.
Besides, one’s cultural and religious beliefs,
coping skills, and psychiatric history; the
availability of support systems; and one’s
socioeconomic status all affect the pattern of
reaction and coping with the loss of a loved
one. However, there is at least a tendency for
people to move between the following stages:
Initial Stage
Initial Shock: A phase of numbness and
disbelief which lasts for hours or days.
Intermediate Stage
™™ Pangs of grief (i.e. yearning): A phase of
intense feelings of longing for the lost
person accompanied by intense anxiety.
These ‘pangs of grief’ are transient episodes
of separation distress between which the
bereaved person continues to engage in the
normal functions such as eating, sleeping,
and carrying out essential responsibilities
in an apathetic and anxious way.
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™™ Disorganization and despair: As time
passes the intensity and frequency of the
pangs of grief tend to diminish, although
they often return with renewed intensity
on occasions such as anniversaries and
birthdays, which bring the dead person
strongly to mind. The bereaved person thus
oscillates back and forth between longing
and despair many times before coming to
the final phase of reorganization.
Recovery Stage
Reorganization (Adjustment): A final phase of
reorganization; grief usually resolves when the
person accepts the reality of the loss, begins
adjusting to the absence of the deceased, and
can think about the deceased without pain.
Individuals develop new relationships, interest
and a new identity is discovered.
Types of Grief Reaction
Although the grief literature has proposed
many types of grief reactions, the fact is
that every individual grieves in his/her own
way. Circumstances vary widely and one
person may react in one way to a loss that
affects another in a completely different
way. However, most literature attempts to
distinguish between normal grief and various
forms of complicated grief. The following
classifications are general and may overlap.
Normal Grief
Uncomplicated or normal grief is believed to
proceed through a series of anticipated stages,
i.e. initial, intermediate, and recovery stages
(vide above).
In general, normal or common grief
reactions are marked by a gradual movement
toward an acceptance of the loss and the
severity of symptoms diminishes over time.
The healing process usually reaches resolution
between 6 months to 2 years. It is common
 330  Section 7: Palliation and Bereavement
for its brief exacerbations brought on events
such as anniversaries, birthdays, holidays; and
sensory reminders, such as hearing a song,
cooking of a dish favored by the decreased.
Grief usually resolves when the person accepts
the reality of the loss, begins adjusting to the
absence of the decreased, and can think about
the decreased without pain.
Complicated (Morbid or Pathological)
Grief
This term has been used to describe distortions
of the normal pattern of grieving. Horowitz et
al define complicated grief as, “the current
experience (more than a year after a loss, i.e.
chronic or prolonged grief ); characterized
by intense intrusive thoughts, pangs of
severe emotion, distressing yearnings, feeling
excessively alone and empty, unusual sleep
disturbances, and maladaptive levels of loss
of interest in personal activities (i.e. most
symptoms of normal grief are absent—a state
referred to as ‘inhibited grief’); and excessively
avoiding or delaying grief reactions at the
time of loss, but expressing them at a future
date where they seem disproportionate to the
situation ( i.e. ‘delayed’ grief’)”.7
The key characteristic of complicated grief
is a significant decline in emotional, physical,
cognitive, behavioral, and social attributes.
Complicated grief is more common
after unexpected and violent deaths such
as suicide,8 and may also be associated with
increased risk of cancer, hypertension, cardiac
events, and suicidal ideation, plus adverse
health behaviors such as increased smoking
and alcohol misuse.9 This syndrome is distinct
from major depression and post-traumatic
stress disorder, but complicated grief may
comorbid with each.10
Risk Factors for Complicated
Grief11
It is important to identify those at risk for
developing complicated or pathological
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grief. Factors increasing risk of developing
complicated grief are outlined in Table
33.2. If physicians are aware of these risks,
interventions in both preventive psychiatry
and management can be instituted.
Family Physician as Counselor
One of the fundamental concepts of family
physicians is to provide care for a wide range
of health issues throughout the lifecycle, from
birth through death, in a variety of settings
within the community.
Family physicians have the ongoing long-
term contract with patients through thick and
thin, and most specifically, in situations where
medical treatment has “failed”. Even when the
person is terminally ill, the efforts concentrate
on the potential of life’s sustenance. In this
process, the family physician shares the pain,
distress and suffering along with the bedridden
and his family.
Table 33.2  Factors increasing risk after bereavement
Personal:
• Low self-esteem
• Concurrent life stressors, employment difficulties
• Presence of premorbid psychiatric problems,
substance abuse
• History of multiple losses
• Past history of grief difficulties
Traumatic circumstances:
• Death of a spouse or a child
• Death of a parent, especially in early childhood
or adolescence
• Sudden, unexpected, untimely deaths (particularly
if associated with horrific circumstances)
Social or cultural:
• Perceived inadequate or absent support system
• Lower socioeconomic class
• Controversial loss (abortion, suicide)
• Ambiguous loss (e.g. kidnapping.)
• Inability to carry out valued religions ritual
Familial or relationship:
• Ambivalent, conflicted, or highly dependent
relationship with the deceased
• Hostile family (high conflict, poor cohesiveness,
low expressiveness)
• Presence of young children in the home
 Chapter 33: Family and the Grief Process 331
In the present contemporary community,
with dominant ‘nuclear families’* the traditional
support to the bereaved from ‘joint families’
is often absent or inadequate. Also, there is
disruption of the ‘extended family members’**
and the lack of support of neighborhood
communities. Within this social context, family
physician has a unique opportunity to offer
bereavement counseling and plays an important
function in helping people express their feelings
and adjust to their loss.
Frequently, grieving people will come
to the family physician complaining of
physical manifestations of normal grief, e.g.
anxiety symptoms, such as tightness in chest,
breathlessness; symptoms of depression, such
as lack of appetite, and lack of energy. Some
people, however, may complain of cognitive
manifestations of normal grief by simply
describing the loneliness and emptiness of
life. In such grief-ridden situations, family
physicians’ unique, intimate relationships
with patients that enriches doctor-patient
relationship, allows physicians to customize
a management plan that is more appropriate
and sympathetic for grieved individuals and
family members.
The family physician, by becoming fully
aware of the reality of the loss, and helping
to overcome various impediments in the
readjustment over the loss, can play a role in
making the family a potential center of strength
for the bereaved.
Guidelines to Manage a Grieving
Person and Family Members12
™™ Be there: One’s presence can be the greatest
gift given to a grieving individual.
™™ Be a good listener: A grieving person needs
to express emotion repeatedly to achieve
*The basic family unit, consisting of father, mother and their biological children.
**Generally a family with parents, their children, the grandparents, and other family members, aunts,
uncles, etc.
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resolution. Silence is an important part of
listening.
™™ Be non-judgmental: There is no right or
wrong way to grieve. Do not impose your
opinions, advice or copying mechanism
on your patient.
™™ Avoid clichés: Comments such as, “its god’s
will”, “don’t cry”, “everything will be okay”,
invalidate the grieving person’s feelings and
beliefs. These comfort clichés can impede
or terminate effective communications.
™™ Be patient: Take your time: Be willing to
spend enough time with a grieving person
so that support, comfort, and reassurance
are effective.
™™ Physical contact: First ask a grieving person
before attempting to provide comfort by
using physical contact. An uninvited or
unwelcome touch may be offensive or
threatening and may cause the patient to
withdraw.
™™ Promises: Do not make promises you
cannot keep. If a request cannot be met, say
so with honesty and compassion.
™™ Confidentiality: Keep every revelation in
confidence unless specific consent is given
to do otherwise.
Referral
When the patient’s grief is causing concern—
showing the following warning symptoms and
signs of decline in health—refer the patient to
a support group that can better address the
patient’s ongoing needs. Being familiar with
the stages of grief (vide above) helps to judge
unfavorable prognosis.
™™ Lack of basic self-care activities
™™ Substance abuse
™™ Multiple losses that can be overwhelming
 332  Section 7: Palliation and Bereavement
™™ Severe withdrawal and/or feelings of
intense depression, hopelessness or apathy
™™ Radical lifestyle changes; decreased
interest and participation in activities he
or she previously enjoyed
™™ Unusual and alarming behavior patterns;
inability to handle routine life and work tasks
™™ Noticeable physical changes, such as
extreme weight loss or gain, severe
headaches, sleep changes, inattention to
personal hygiene and appearance
™™ Suicidal feelings (if your loved one
mentions suicide—even in a joking
manner—take him or her seriously and
seek immediate professional help).
Conclusion
™™ The experience of grief and loss are
universal
™™ People grieve in their own way. Some may
take longer to heal than others
™™ A high degree of suspicion is essential to
detect complicated grief reactions needing
expert therapy
™™ With an established relationship and
familiarity with the family and culture,
family physicians have an advantage in
identifying and assisting grieving patient
™™ Dealing with grieved individual helps us
become not only better physician, but also
better human beings.
References
1. Boelen PA. Symptoms of prolonged grief,
depression, and adult separation anxiety:
distinctiveness and correlates. Psychiatry
mebooksfree.com
Res, 2013;207(1-2):68–72. doi: 10.1016/j.
psychres.2012.09.021. Epub 2012 Oct 12.
[PMID: 23068081: Abstract].
2. Stammel N, et al. Prolonged grief disorder
three decades post loss in survivors of the
Khmer Rouge regime in Cambodia. J Affect
Disord, 2013;144(1-2):87–93. doi: 10.1016/j.
jad.2012.05.063. Epub 2012 Aug 4.[PMID:
22871529: Abstract].
3. Shear MK, et al. Bereavement and anxiety.
Curr Psychiatry Rep, 2012;14(3):169–75. doi:
10.1007/s11920-012-0270-2. [PMID: 22538558:
Abstract].
4. John Murtagh. General practice, counseling
skills: 1996;28.
5. Parkes CM. Bereavement in adult life. BMJ,
1998;316(7134):856–9. [PMID: 9549464: Free
PMC Article].
6. Breen LJ, et al. The fundamental paradox in
the grief literature: a critical reflection. Omega
(Westport), 2007;55(3):199–218. [PMID:
18214068: Abstract].
7. Horowitz MJ, et al. Diagnostic criteria for
complicated grief disorder. Am J Psychiatry,
1997;154(7):904–10. [PMID: 9210739; abstract].
8. Mitchell AM, et al. Complicated grief and
suicidal ideation in adult survivors of suicide.
Suicide Life Threat Behav, 2005;35(5):498–506.
[PMID: 16268767: Abstract].
9. Prigerson HG, et al. Traumatic grief as a risk
factor for mental and physical morbidity.
Am J Psychiatry, 1997;154(5):616–23. [PMID:
9137115: Abstract].
10. Miller MD. Complicated grief in late life.
Dialogues Clin Neurosci, 2012;14(2):195–202.
[PMID: 22754292: Free PMC Article].
11. Frances Sheldon. Bereavement (abc of
palliative care). BMJ, 1998;316:456–8.
12. Carnnell C.W.PA-C.Guiding your patient
through the grieving process. - JAAPA -
December 1997.
 8
Section

Prevention and
Health Care
™™ Prevention in Family Practice
™™ Preventive Care Delivery: Barriers and Remedies

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 34 Prevention in
Family Practice

“The purpose of medicine is to make available to all the people, in the greatest possible
degree, the achievements of science as they relate to the promotion of health and
to the prevention and treatment of disease.”
WG Smillie, MD
Prof. of Public Health
and Preventive Medicine
New York Hospital.1

The Power of Prevention fewer hospitalizations and surgeries, took fewer

The old saying, “an ounce of prevention is
worth a pound of cure” is no exaggeration and
has a lot of truth in it; and never more so today
when it seems likely that the most dramatic
advances in saving lives lie in preventing
diseases rather than curing them.
In recent times, there has been a paradigm
shift in medicine from the “curative model”*,
which has wrongly equated the health with
lack of disease to “health promotion and
disease prevention-model”** which aims at
improving the health status of individuals and
consequently the community.2,3
Numerous research studies over the
last few years have shown that people who
began paying attention to real preventive
healthcare in midlife—stopped smoking,
exercised, and made dietary changes—had
medications, and lived longer than people who
didn’t.4
Although the primary goals in medicine are
prevention of disease and promotion of health,
the present biomedical advances, coupled with
improved living and educational standards of
the public have opened up number of avenues
to prevention. The horizons of preventions
in medicine have extended far beyond the
medical field. For example, interactive health
communication using internet technologies
is expanding the range and flexibility of
intervention and teaching options available
in preventive medicine and health sciences
for delivering automated, self-instructional
health behavior-change programs through
the Internet.5,6 Further, with the ability to help
predict disease risk and enable preemptive

*Treatment and therapies provided to a patient with intent to improve symptoms and cure the patient’s
medical problem, generally using antibiotics, chemotherapy, etc.
**For example—immunization, cervical screening, smoking cessation, fluoridation of water, etc. Preventive
medicine aims to improve and maintain health by ensuring people do not fall ill in the first place. On the
contrary, curative medicine restores and maintains health by treating people after they fall ill. Curative
medicine does emphasize in practice to alleviate pain and suffering for a time, but ignores critical factors
that contribute to the persistence of disease.

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 336  Section 8: Prevention and Health Care
health plans, genome-guided preventive
medicine has the potential to improve
population health on an individualized level.7
Modern preventive medicine has been
defined as, “The art and science of health
promotion, disease prevention, disability
limitation and rehabilitation“.8 It is in this
context family physicians have to integrate
their services for not only curative, but also
promotive, preventive, and educational
aspects of health, which have also been
emphasized in the Alma – Ata Declaration.9
Prevention—Family Physician’s
Role
Family practice is regarded to have the most
potential in prevention,10,11 the most obvious
reason being, family physicians care for patients
in many different environments, including the
home and settings that are underserved by
other medical providers. Patients, therefore,
have better access to their family physicians
and primary health care providers. Working in
partnership with patients, and the progressive
doctor-patient relationship established by
frequent contracts, family physicians play
essential roles as educators, interpreters, and
advocators for promoting health and preventing
diseases of individuals, their families, and the
community at large.
Family physicians continue to be the
first contact for all patients, requiring
patient-centered, culturally-appropriate
and continuous source of care, regardless of
income, insurance status, or race/ethnicity.
Further, according to data released by the
Agency for healthcare Research and Quality,
family physicians provide more healthcare
to rural areas than other primary care or
subspecialty physicians.12
Since family physicians understand
the whole person in the context of their
environment, track their healthcare through
different stages of life, and usually take care of
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family members too, they play an important
role in disease prevention and health education
to the community and thus improve their
quality of health.
As the key providers of primary medical
care, family physicians have a central role in
the prevention of disease and there is evidence
that physicians in their practice can effectively
provide preventive care that reaches the
majority of the population.13
Prevention—Limiting Factors
While public health education is vital
to improving overall health in developing
countries, education does not always predict
compliance with medically proven health
practices.14
It’s a common knowledge that, in spite
of extensive health education programs,
individuals and families, whether sick or well,
spend far more time making independent
decisions, such as when to go to a doctor or
clinic, where to go, and whether or not to
follow the advice they receive from health
workers, and do so with minimal training or
information.
As a result of such detrimental behavior,
untold number of people die unnecessarily,
not because they have a disease for which there
is no cure, but because they did not go to their
doctors for investigations and treatment soon
enough.
Today, with the rapid advances in medical
treatment, early diagnosis is of vital importance
in preventing unnecessary tragedies, because
many of the modern treatments are curative
only if applied in the initial stages of illness.
It is clear, therefore, that the limiting factor
in all too many cases of illness today lies not
in what the doctor can do, but in whether the
patient comes to seek medical advice in time.
If such millions of decisions are to be made
wisely, people need to be equipped with the
knowledge and skills necessary to exercise
 Chapter 34: Prevention in Family Practice 337
individual and community responsibility.
Primary barriers to preventive service utilization
such as ability to pay, perception of need, service
availability, accessibility of services, and cultural,
gender, racial, and religious barriers have to be
resolved.15,16 Any effective method of helping to
persuade people to seek medical help early is
thus likely to be more effective in saving lives.
Primary health care, therefore, is the prime
source to implement health promotion and
health education—to make people more aware
of what they can do for themselves by increasing
their knowledge about how they themselves can
affect their own health.
Promoting Prevention
Physicians and associated health care
professionals have a duty to ascertain that
the facts about disease prevention and health
education are delivered to the community in a
form that they can comprehend. To be effective
in this role, family physicians need to be:
™™ Opportunistic in offering preventive care
when patients present with other problems
and concerns
™™ Anticipatory in routinely assessing the
preventive care needs of their patients
™™ Proactive in targeting preventive care most
intensively to high risk individuals and
reaching all of their patients, especially those
who are least likely to seek out assistance.
This involves looking beyond the individual
consultation to the population of patients
we serve, e.g. we know that to be effective in
immunization or screening programs, we must
reach a large proportion of patients at risk in our
practice or community. However, to reach this
ideal is difficult. Each preventive activity uses
up some of the available time that physicians
have with their patients. Therefore, only those
activities and measures, which have been
proved to be cost effective by carefully designed
studies and have relevance to family practice,
need to be integrated and followed diligently.17
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Levels of Preventions and
Screening
Primary Prevention
Primary prevention, (i.e. health promotion
and specific protection), prevents disease
from occurring by removing its cause. As a
result there is no disease. It also includes the
concept of “positive health”—a concept that
encourages achievement and maintenance
of “an acceptable level of health that will
enable every individual to lead a socially and
economically productive life”. It concerns
individual’s attitude toward life and health,
and the initiatives taken about positive and
responsible measures for self, family, and the
community.
Primary prevention strategies include:
™™ Immunization against many communic­
able diseases.
™™ “Health education” to bring changes in
life style, factors known to be associated
with diseases, e.g. smoking cessation,
healthy balanced diet, exercise, reduction
in alcohol intake, safe sexual activity, use
of seat belt and bicycle helmet, use of job
specific protective devices such as ear and
eye protection from toxic exposure.
™™ In addition to these individual activities,
communities may provide primar y
prevention through sanitation, keeping
water supply clean and disposing efficiently
sewage and industrial wastes.
Secondary Prevention
Secondary prevention (i.e. early diagnosis
and prompt treatment) detects disease when
it is asymptomatic and when early treatment
can stop it from progressing. It is largely
the domain of clinical medicine. By early
diagnosis and adequate treatment, secondary
prevention attempts to arrest disease process
and restore normal health. It may also protect
others in the community from acquiring the
 338  Section 8: Prevention and Health Care
infection and thus provide at once secondary Opportunity for Prevention
prevention for the infected individuals and
Physicians must take every opportunity to
primary prevention for their potential contacts.
deliver preventive services, especially persons
Examples of secondary prevention are
with limited access to care. Those individuals
community-screening programs to detect
at highest risk for many preventable causes
hypertension, glaucoma, mammography,
of premature disease and disability, such
and pap smear examination for screening of
as tuberculosis, poor nutrition, human
cervical cancer.
immunodeficiency virus infection, cervical
Tertiary Prevention cancer, are the same individuals least likely to
receive adequate preventive services. Devising
Tertiary prevention (i.e. disability limitation
strategies to increase access to preventive
and rehabilitation) refers to management
services to such individuals is more likely to
of established disease so as to reduce
reduce morbidity and mortality from these
complications and disability. Examples
conditions then performing preventive
include comprehensive management of
services more frequently or those who are
diabetes in order to reduce complications and
already regular recipients of preventive care
improve functional status, and post myocardial
and who are often in better health.
infarction medications to reduce the incidence
One important solution is to deliver
of re-infarction. A patient who has suffered
preventive services at every visit, rather than
a stroke because of hypertension may be
exclusively during visits devoted entirely on
restored to a useful lifestyle with appropriate
prevention. Any visit provides an opportunity
rehabilitation. Maximizing the quality of life is
to practice prevention. In fact, some individuals
one of the key goals within the framework of
may see clinicians only when they are ill or
any tertiary preventive strategy.
injured. The illness visit provides the only
Screening opportunity to reach individuals who, due
Screening (Table 34.2) is often mentioned to limited access to care, would be otherwise
in the same context as prevention activities. unlikely to receive preventive services.
Screening may be defined medically as the Some specific opportunities, in family
identification of an unrecognized disease practice wherein primary prevention can be
or risk factor by history taking, physical practiced par excellence are:
examination, laboratory test, or other ™™ Antenatal care

procedure. It separates people who are ™™ Postnatal care

apparently well but have a disease or risk factor
for a disease from those who do not. Screening
may also be a part of some primary and
secondary prevention approaches. However,
it should not be considered diagnostic.
™™ Pre-marital checkup*
™™ Periodic health examination
™™ Health insurance examination
™™ Pre-employment and pre-placement
health examination**

*It’s a comprehensive group of tests meant especially for those who are planning to get married. The tests
are designed to identify potential health problems that may have an impact on one’s fertility and also to
detect some of the hereditary diseases and infections.
**A Pre-employment medical is a medical exam or health assessment of an employee, which can be used
as part of the decision of whether to make a job offer to a prospective employee.
A Pre-placement medical is a medical conducted after the employee has been extended a job offer, but
before they have been ‘placed’ in the position.

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 Chapter 34: Prevention in Family Practice 339
™™ Traveling overseas health examination
™™ At times of crisis or potential crisis
™™ (e.g. mass immunization after natural
disaster)
™™ School health services
™™ Industrial medical services
These various opportunities are, of course,
not found in neat compartments. They are
intermingled with one another and with the
day-to-day tasks of diagnosing and treating
illness. They are found in private practice and
also in community programs in which the
doctor actively participates.
Scope for Prevention
In general, preventive medicine must be a
component in the professional service of
every practicing physician. Irrespective of
the individual’s specialty, physicians should
include attention to preventive medicine as
an integral part of every office visit.18
Ideally all family physicians should work
toward the prevention of avoidable death
and illness within the community. Family
physicians have the greatest potential in
achieving this goal as they see a wide range of
patients and are more likely to be familiar with
their family background and lifestyles.
Consultations are the common
professional encounters in family practice and
frequently present opportunities to discuss
health promotion issues. A brief, direct and
meaningful advice offered to people by the
doctor regarding life style behavior changes
to promote health is helpful. Although this
may not be seemingly apparent to doctors,
much can be achieved by brief and repeated
counseling, reinforced over a period of time,
resulting in small but permanent behavioral
changes to individuals under their care.
There is evidence that brief interventions
can be effective.19,20 Most of these are consistent
with the 5A’s approach first developed as a
framework for reducing alcohol consumption,
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but which has been applied to the management
of all the behavioral risk factors in primary
healthcare (Table 34.1).21,22
Common preventive activities in family
practice include the following:
™™ Specific screening
™™ Immunization
™™ Health promotion, disease prevention, and
education
™™ Physical checkup
Screening
Screening is an integral part of good family
medicine. It allows early detection and sub­
sequent treatment of disorders. For example:
™™ Developmental screening: For children,
generally from birth through 3 years of age,
to access height, weight, head circumference,
vision, hearing, speech, nutritional status,
emotion, mental functions, etc. Any
concerns raised during surveillance should
be promptly addressed with standardized
developmental screening tests.
™™ Women: Screening for breast and cervical
cancer.
™™ Adults and elderly patients: Screening
for chronic disease and disabilities like
hypertension, diabetes, mental and
emotional problems, etc. (Table 34.2).
Table 34.1  The 5As approach
ASK: Ask all patients about smoking, nutrition, alcohol
or physical activity
ASSESS: Readiness to change, dependence
(smoking and alcohol)
ADVISE: Brief, nonjudgmental advice with patient
education materials (such as Life scripts) and
motivational interviewing
ASSIST: By providing motivational counseling and
a prescription (life script or pharmacotherapy if
indicated for nicotine or alcohol dependence)
ARRANGE: Referral telephone support services,
group lifestyle programs or individual provider (e.g.
dietician or exercise physiologist) and a regular
follow-up visit
 340  Section 8: Prevention and Health Care
Table 34.2  Routine preventive health measures for adults
Service Age Ages 18–39 Ages 40–64 Ages 65 and Over
Physical exam Recommended every 1–3 years to include Recommended Recommended once a year
the following: every 1–3 years to include the following:
• Blood pressure to include the • Blood pressure
• Height and weight following: • Height and weight
• Blood • Consideration of
pressure hearing and vision
• Height and screening
weight • Consider TSH if any
signs or symptoms of
hypothyroidism
Prevention of • See diet and exercise, avoid tobacco • Blood • Blood cholesterol
heart disease • Blood cholesterol with HDL every five cholesterol every 5 years to age
years for males, beginning at age 35 every five 75 years
years for men • See nutrition and
and women exercise, avoid
age 45 years tobacco
and older
• See nutrition
and exercise,
avoid tobacco
Other • Consider • Consider diabetes
screening and diabetes screening if not done
prevention screening, age in last 3 years (also
45 years (also see diabetes risk
see diabetes factors below)
risk factors • Counsel regarding
below) risks and benefits of
hormone replacement
therapy
Cancer Breast cancer • Clinical breast • Clinical breast • Mammogram and
screening exam suggested exam once a clinical breast exam
as part of the well year once a year
woman exam • Mammogram
every 1–2
years between
age 40 and 50
years annually
beginning at
age 50 years
Cervical cancer • Pap smear • Pap smear • Pap smear every
every 1–3 years, every 1–3 3 years (at the
depending on years, discretion of patient
prior Pap smear depending and physician, these
results and on prior Pap may be discontinued
other risk factors smear results if there has been a
including sexual and other long history of normal
history risk factors Pap smears)
including
sexual history
Prostate cancer • For men age 50 years and older, discuss
risks and benefits of screening
Colorectal cancer • Fecal occult blood (a test for blood in
the stool) every year beginning at age
50 years and sigmoidoscopy every 4–5
years1 (also see risk factors below)
Contd...

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 Chapter 34: Prevention in Family Practice 341
Contd...
Immunizations • Tetanus booster • Tetanus booster • Tetanus booster every 10 years
every 10 years every 10 years • Flu shot annually
• MMR • MMR • Pneumococcal vaccine: once
recommended if recommended
no serologic proof for all non-
of immunity or pregnant women
documentation of of childbearing
a dose given on age born after
or after the first 1956 with no
birthday evidence of
rubella immunity
or vaccination
Safety • Lap/shoulder belts, bicycle/motorcycle or • Same as other adults with addition of fall
and Injury All-terrain vehicle (ATV) helmets precautions
prevention • Smoke detectors, firearms safety, • Remain alert for signs of elder abuse
avoidance of smoking near bedding or
upholstery
• Be alert for signs of domestic violence
Substance • Routine screening for tobacco use and counseling regarding adverse effects of tobacco
use • Be alert for signs of substance abuse, counseling regarding avoidance of excessive
alcohol, under-age drinking, avoid alcohol during pregnancy and while driving, boating,
etc.
Nutrition and • Limit fat and cholesterol, maintain caloric balance, emphasize fruit, vegetables and
exercise grains, adequate calcium intake
• Folic acid supplementation for women in child-bearing years
• Regular physical activity
Sexual • Reproductive awareness, contraceptive options, avoid high risk sexual behavior and risk
practices of sexually transmitted disease
Dental care • Floss and brush daily with fluoride containing toothpaste, regular visits to a dentist

Childhood Immunization Table 34.3  Concept of health promotion and disease

prevention
Childhood immunization is an example of
Health Promotion Disease Prevention
a successful preventive health program for
Alcohol and drug Audiometric screening
better health in the community. Small pox has avoidance Blood pressure
been eradicated on a global basis. Presently Breast self-examination Screening
poliomyelitis is on the verge of extinction. Exercise Focal occult blood
Low fat diet testing
Besides supervising and administrating
Reducing ultra-violet Immunization
vaccination, the family physician has a light exposure Lipid screening
special duty to perform to clear ignorance and Safe sex Mammography
superstitions prevailing in the community with Seat belt use Pelvic exam and pap
Helmets for bicycle smear
regards to immunization. Riders Sigmoidscopy
Testicular self Tuberculosis
Health Promotion and Disease examination Weight control
Tobacco avoidance
Prevention (Table 34.3)
World Health Organization defines “health physical and emotional well-being that
promotion” as, “the process of enabling increases length, vitality, and quality of life.
people to increase control over and improve “Disease prevention” refers to activities
their health.” It is the application of methods f o c u s e d o n h e a l t h r i s k p ro f i l i n g o f
and adoption of healthy practices that foster asympto­matic persons and appropriate use

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 342  Section 8: Prevention and Health Care
of screening tests for early detection of disease,
followed by patient education and therapeutic
intervention when indicated.23
The Centers for Disease Control and
National Center for Chronic Disease Prevention
and Health Promotion has developed a variety
of tools and resources to aid professionals,
public health professionals, policymakers, and
other stakeholders in their chronic disease
prevention efforts.24
Health Education
Health education is the provision of information
about how to maintain or attain good health.
It is a “dynamic ever changing process of
development in which a person is accepting or
rejecting new information, new attitudes, and
new policies concerned with the objectives
of healthful living”. Health education, then, is
concerned with getting people to act in ways
deemed favorable to prevention at all levels—
primary, secondary, and tertiary. The needs
and interests of individuals, families, groups,
organizations, and communities are at the heart
of education programmes, which provide many
opportunities for practicing health education.
Family physicians have a central role to
play, and family practice provides a potentially
important setting for a community approach
in providing health education. They are in a
favorable position, as acknowledgeable and
respected figures, in advising and influencing
their patients and constitute a credible source
to convey important messages and to change
patient’s behavior. Areas of particular concern
are lifestyle, self-care, smoking, alcohol and
drug abuse, STD, HIV and AIDS infections,
sexual behavior, domestic and traffic accidents
and mental health. Much can be achieved by
family physician in this respect because they
are often the first health professionals to be
consulted for health related matters.
The Royal Australian College of General
Practitioners 25 has described how health
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promotion and education can be imparted at
different levels in general practice, namely:
Level 1: Reception area: use of brochures,
postures and display of other visual and
audiovisual techniques.
Level 2: Life style measures: e.g. making
premises no smoking areas.
Level 3: Consultation: Opportunistically asking
and recording smoking habits, alcohol intake,
diet, exercise, and family dynamics.
Level 4: Patient Follow-up: Special arrange­
ments may be made to determine progress and
modify subsequent management in specific
areas.
Level 5: Special Clinics: Antenatal clinics, child
survelleillance clinics, family planning clinics
and those for specific disease management
such as hypertension and diabetes.
Computer software, medical internet web
sites, and CD-ROMs are the current high-
tech methods of education that have made
a significant impact on health promotion,
disease prevention, and health education.
Other electronic resources such as educational
voice messages, automated and/or interactive
phone follow-up and support, interactive
computer programs, and electronic patient-
doctor communication provide tailored
information and feedback or address health
concerns.
Patient Education
The primary aim of a physician should not
be merely treating an illness, but rather to
help people to remain healthy, and patient
education is vitally important in this respect.
However, for individuals to realize the benefits
of health education requires a high level of
engagement, but ultimately result in improved
long term outcomes and significant clinical
benefits as seen from trials of self-management
or lifestyle interventions across conditions
 Chapter 34: Prevention in Family Practice 343
such as diabetes, coronary heart disease, heart
failure and rheumatoid arthritis.
The obvious benefits of patient education
include improved quality of care, improved
patient satisfaction, increased compliance,
improved staff satisfaction, and effective use
of resources.
Other beneficial issues that are contri­
butory to increasing the public health impact
of patient education include:
™™ Participation and advocacy: Patients are
allowed to participate in making their
decisions as equal partners; as a result
patients are more satisfied.
™™ Internet-based education: In the present
days of information technology, internet
access is rapidly changing the landscape of
health information. The number of patients
bringing internet-based health information
to physicians is on the rise. Intelligent
patients do have updated knowledge about
many advances, especially related to their
illness. However, whether health information
found on the internet is helpful for patients
in clinical consultations appears to depend
on the how patients use the information they
retrieve, as well as on physicians’ affective
responses to these patients. Discussions
with such patients and their aliments provide
a unique opportunity for physicians to
streamline the delivery of health information
and services.26
™™ Risk management: Patient education is
the only sure away to prevent malpractice
claims. Explanations given to patients’ and
families in the management of their illness,
and its prognosis; confirming patient is
made fully aware of treatment scope,
alternatives and risks (i.e. informed consent)
reduce the risk of doctors being sued if
complications do occur. Such protocols
are an integral part of risk management in
defensive medical practice today.
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Not educating a patient about their
care for reasons of such as lack of time, or
indifference to patients’ clarifications and
understanding leaves the patient at risk of
having complications. These complications
can cause unnecessary admissions to the
hospital, an increase in medication costs and
financial burden to the patient, family and
insurance company. Educating the patient is
an effective way to prevent these complications
and also thwart any new diseases from
occurring.27
Physical Check-ups28
Many practices provide pre-employment
examinations, physical check-ups, medical
examination for immigration application, and
similar periodic health evaluation schedules,
including complete physical examination,
and routine biochemical, hematological tests,
and other specific screening tests. Depending
on one’s age, health and family history, and
lifestyle choices such as diet, physical activity
and smoking provide an opportunity to early
detection of any illnesses. It is crucial for
physicians to integrate preventive care guidelines
and provide access to evidence-based preventive
health services to infants, children and adults at
routine health check-ups.
Conclusion
Prevention and health promotion must be
viewed as a responsibility to be shared among
all healthcare providers, rather than the
sole responsibility of any medical specialist.
However, family physicians have a special
opportunity to be an effective force in disease
prevention and health promotion.
Although immunizations and screening
tests remain important preventive services, the
most promising role for prevention in current
medical practice lies in changing the personal
health behaviors of patients long before
 344  Section 8: Prevention and Health Care
clinical disease develops. This is the prime aim
of health promotion—to make people more
aware of what they can do for themselves and
educating them about how they themselves
can affect their own health.
References
1. The NEJM, January 12, 1950;242(2).
2. Orlandi MA. Promoting health and preventing
disease in health care settings: an analysis of
barriers. Prev Med, 1987;16(1):119–30. [PMID:
3823010: Abstract].
3. Sevel F. Designing effective health promotion
and disease prevention programs. Health Values,
1990;14(1):32–7. [PMID: 10106347: Abstract].
4. The p ow er of prevention. CD C ; U.S.
Department Of Health and Human services,
2003.
5. Fotheringham MJ, et al. Interactive health
communication in preventive medicine:
internet-based strategies in teaching and
research. Am J Prev Med, 2000;19(2):113–20.
[PMID: 10913902: Abstract].
6. Lintonen TP, et al. Information technology
in health promotion. Health Educ Res, 2008;
23(3):560–6. Epub 2007 Feb 13. [PMID:
17301059: Free Article].
7. O’Daniel JM. The prospect of genome-guided
preventive medicine: a need and opportunity
for genetic counselors. J Genet Couns, 2010;
19(4):315–27. doi: 10.1007/s10897-010-9302–4.
Epub 2010 May 4. [PMID: 20440545: Abstract].
8. Park K. Park’s TB of P & SM 17th edn.: p.7.
9. L a w n J E , e t a l . A l m a - A t a 3 0 y e a r s
on: revolutionary, relevant, and time to
revitalise. Lancet. 2008;372(9642):917–
27. doi: 10.1016/S0140-6736(08)61402-6.
[PMID:18790315:Abstract].
10. Pelletier-Fleury N, et al. Preventive service
delivery: a new insight into French general
practice. Health Policy, 2007;83(2-3):268–76.
Epub 2007 Mar 21. [PMID: 17368859: Abstract].
11. Katić M, et al. Preventive work in family
medicine—proactive approach. Acta Med
Croatica, 2010;64(5):443–52. [PMID: 21692269:
Abstract].
12. Primary Care Workforce Facts and Stats No. 3.
January 2012. Agency for Healthcare Research
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and Quality, Rockville, MD. Web site : http://
www.ahrq.gov/research/findings/factsheets/
primary/pcwork3/index.html (Accessed on
07-07-2013).
13. Common Wealth Dept. of health and family
services. General Practice in Australia, 1996.
14. Hanna Saltzman. Barriers to Oral Rehydration
Use Among Ghanaian Mothers. The Journal of
Global Health. Web site:
http://www.ghjournal.org/jgh-print/spring-
2012-print-issue/limitations-of-health-
education/ (Accessed on 06-07-2013).
15. Fowler-Brown A, et al. Perception of racial
barriers to health care in the rural South. J
Health Care Poor Underserved. 2006; 17(1):86–
100. [PMID: 16520516: Abstract].
16. Disparities in Healthcare Quality Among Racial
and Ethnic Groups: Selected Findings From
the 2011 National Healthcare Quality and
Dispar. September 2012. Agency for Healthcare
Research and Quality, Rockville, MD.
Web site : http://www.ahrq.gov/research/
findings/nhqrdr/nhqrdr11/minority.html
(Accessed on 08-07-2013).
17. Guidelines for preventive activities in General
Practice. The Royal Australian College of GPs:
Redbook, 8th ed., April 2009. Web site:
https://www.racgp.org.au/your-practice/
guidelines/redbook/introduction/
introduction/( Accessed on 08-07-2013).
18. James WC. Preventive medicine as a component
of the office visit – Is it time to change? West J.
Med, 1994;161:181–83.
19. Peteella RJ, et al. Does counseling help patients
get active? Systematic review of the literature.
Can Fam Physician, 2002;48:72–80 [PMCID:
PMC2213933: Abstract].
20. Clio Spanou, et al. Preventing disease through
opportunistic, rapid engagement by primary
care teams using behaviour change counselling
(PRE-EMPT): protocol for a general practice-
based cluster randomized trial. BMC Family
Practice; September 2010;11:69, [open access],
(accessed on 09-07-2013).
21. Screening and Behavioral Counseling Inter­
ventions in Primary Care to Reduce Alcohol
Misuse Am Fam Physician, 2004;70(9): 1743–4.
Web site: http://www.aafp.org/afp/2004 /1101/
p1743.html (Accessed on 09-07-2013).
 Chapter 34: Prevention in Family Practice 345
22. Goldstein MG, et al. Multiple behavioural risk
factor interventions in primary care: Summary
of Research Evidence. Am J Prev Med, 2004;27:
61–79.
23. Am Assoc Fam Phy. Recommended core
Educational guidelines for Fam Pract
Residents: health Promotion and disease
Prevention; Revised 6/2012 by Floyd Family
Medicine Residency Program.
24. CDC:Chronic Disease Prevention and Health
Promotion. Web site:
http://www.cdc.gov/chronicdisease/resources/
index.htm (Accessed on 09-07-2013).
25. RACGP. Providing quality prevention
information. Web site:
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http://www.racgp.org.au/your-practice/
guidelines/greenbook/applying-the-framework-
strategies,-activities-and-resources/ability/
providing-quality-prevention-information/
(Accessed on 09-07-2013).
26. Ahmad F, et al. Are physicians ready for patients
with Internet-based health information? J Med
Internet Res. 2006;8(3):e22. [PMID: 17032638:
Free PMC Article].
27. Jernigan Kristie. The Importance of Patient
Education. Suite. 2013;101.
28. CDC - Regular Check-Ups are Important
Web site: http://www.cdc.gov/family/checkup/
(Accessed on 09-07-2013).
 PREVENTIVE CARE

35 DELIVERY: BARRIERS
AND REMEDIES

Prevention…the true aim of medicine is not to make men virtuous, it is to safeguard and rescue them from
the consequences of their vices. The physician does not preach repentance; he offers absolution.
HL Mencken*
“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”
“If doctors are to remain relevant to the changing needs of society, they have to shape their roles within
the context of total human development”.
Martin Luther King Jr

Overview active participation by the patient with

guidance and support from physicians. 1, 2
Health care professionals have always
One of the evidence based and cost-
intuitively acknowledged the value of
effective approach to reduce the impact of
prevention. The benefits of incorporating
NCDs and to strengthen their early detection
prevention into medical practice have become
and timely treatment is through a primary
apparent over the past four decades. The
healthcare approach. The most promising
incidence of previous debilitating conditions
remedy may lie in changing the personal
such as poliomyelitis, diphtheria, and pertussis
health behavior of patients long before
has declined following the introduction
clinical disease develops. Evidence shows that
of preventive health services. But, on the
such interventions are excellent economic
other hand, there is growing evidence of
investments because, if applied to patients
increasing mortality and morbidity linked
early, can reduce the need for more expensive
to trauma and chronic conditions related to
treatment.
individual behavior. A significant proportion
of noncommunicable diseases (NCDs) such
as heart disease, stroke, diabetes, chronic
Barriers to Prevention
respiratory disease, and cancer can be Although, preventive healthcare services have
attributed to patient behavior. While mortality become an integral component of primary care
from some of these conditions is decreasing, practice, studies have shown that physicians
morbidity from most NCDs continues to often fail to provide recommended clinical
increase. For these conditions, prevention preventive services, and that compliance with
at all levels—primary (preventing disease), guidelines has been found to be unsatisfactory
secondary (early diagnosis), and tertiary for most types of preventive services.3 Surveys
(preventing or slowing deterioration) requires indicate that, although general practice

*HL Mencken. Screening and the family physician, Can Fam Physician. 2009;55(2):121.

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 Chapter 35: Preventive Care Delivery: Barriers and Remedies 347
has the potential to play a major role in
disease prevention, family physicians are not
maximizing the opportunities, which present
in every day practice to deliver preventive care.
A number of other studies have concluded
that, although vast majority of primary care
physicians believed it was definitely their
responsibility to educate patients about risk
factors and help them to adhere to their
regimens, they felt inadequate in doing so.4-8
Although, the message is simple—deliver
evidence-based clinical preventive services to
help keep people healthy and save lives—yet,
research shows that even the most effective and
accepted preventive services are not delivered
regularly in the primary care setting.9 ,10
There are many barriers suggested to
explain the failure to provide adequate
preventive services (Table 35.1). Further, these
barriers can be systematically classified into
three groups as those:
™™ Related to the organization of practice,
™™ The patient
™™ The doctor factors.11
Organization of Practice
The government out-patient clinics are
overcrowded. Many are understaffed. This
results in limited time available for each
consultation. Lack of time is also a major
barrier in some private practices as some busy
physicians may see too many patients per day.
Physicians report they do not have enough
time to provide preventive services because
most of their time is spent responding to
patients’ need for treatment. If physicians
were to provide all services recommended
by preventive service guidelines, it has
been estimated that it would require 7.4
working hours per day.12 Because physicians
clearly cannot spend this amount of time on
prevention, they are forced to forego some
services either by omitting them completely
or addressing them only briefly.13
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Table 35.1  Barriers to effective clinical care
• Insufficient time with patients to deliver the range
of recommended preventive services
• Lack of knowledge of services offered for
preventive care
• Economic implications—such as the cost or
routing screening
• Fragmentation of healthcare delivery
• Different recommendations from multiple sources
• Poor reimbursement for preventive care services
• A lack of willingness for the patient to pay for
preventive healthcare services
• Poor reimbursement for preventive care services
• A patient’s lack of motivation for making lifestyle
changes
• Lack of knowledge or skepticism about the
effectiveness of services
• Doctors lack of necessary training to implement
preventive care services
• Complications or adverse events of some
prevention interventions, particularly when given
to healthy individuals
Documentation and maintaining medical
records of patients is yet to develop into a proper
process in the large number of smaller clinics
and hospitals that cater to a large section of
the people in many countries. Further, health
records do not usually have a separate summary
sheet of preventive care in the patient’s file, which
facilitates ease of retrieving specific information.
It is very time consuming to go through the
clinical notes to try to find the right information.
Most doctors will probably give up after a quick
search of the notes if they are unable to find the
necessary information.
These two factors—lack of time and
incomplete health records—resulting in
inadequate system of tracking, monitoring and
follow-up of delivery of preventive services,
make it virtually impossible to carry out any
meaningful prevention, as continuity of care
is not possible.
The Patient
Religious and Cultural Factors
People in the community are strongly
influenced by the prevailing culture, which
 348  Section 8: Prevention and Health Care
has a direct impact on their health-belief
model.14,15 Not all customs and beliefs are bad;
some have positive values, e.g. all religions,
with the well-being of humans at heart, are in
a position to show disfavor with tobacco use, if
not to prohibit it totally. Also, religious people
tend to live longer than the non-religious,
in part because they smoke less.16,17 On the
contrary, some customs and beliefs may be
useless or positively harmful, e.g. Flores18
reported that Latino parents sometimes
have false beliefs about the cause of certain
illnesses and therefore are more likely to
delay vaccinations in children and use home
remedies.
Some cultural beliefs, which continue to be
followed by centuries of practice, have come in
the way of implementing health programmes.
In communities, where health system is the
coexistence of multiple health traditions,
patients attribute an illness to supernatural
factors—people believe that God is punishing
them for bad behavior and making them ill;
diseases like leprosy, tuberculosis are a curse
of past sins; hysteria and epilepsy are due to
invasion of ghost/spirit into the body, and the
services of an exorcist are sought to drive away
the evil spirit or ghost, and promote prayer or
other spiritual interventions that counter the
presumed disfavor of powerful forces.
As can be seen, various religious and
cultural practices bring their own perspectives
and values to the healthcare system, which
frequently create barriers to care. Such barriers
have been further compounded by differences
in language and education between patients
and providers from different backgrounds.
Absence of Symptoms and Motivation
It is a common observation that many patients
often neglect warning symptoms, especially so
when an illness is in its early incubation stages.
The symptoms are often mild and unobtrusive
as to be undistinguishable from the discomfort
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and distresses of every-day life. While this ‘watch-
and-wait’ policy is an acceptable approach in
clinical practice in certain low risk patients,
many patients tend to neglect even when
alarming symptoms and signs develop, and delay
medical aid. For example, an elderly patient
with headache may attribute it to stress, but its
recurrent occurrence with visual deficit may be
further attributed as common refractory error,
when in fact this patient may have impending
vision loss due to giant call arteritis. A timely
ophthalmic intervention could have saved
catastrophic outcome in such patients.
Further, initially asymptomatic NCDs,
such as diabetes, hypertension, obesity, and
immunodeficiency diseases, 19 when not
detected and treated in their initial stages, can
develop life-threatening complications later.
Thus, lack of awareness and motivation on
the part of patients, to seek health screening
measures initially, is a major barrier in
promoting preventive care to such patients.
Adequate education about disease prevention
is crucial in improving outcomes with
preventive guidelines.
Doctor Shopping
Doctor shopping may be defined as the
changing of doctors without a professional
referral during the same illness episode, or
consulting multiple doctors during the same
illness period.20
The reasons for doctor shopping are
varied. Some relate to clinician factors, such
as inconvenient office hours or locations,
long waiting times, personal characteristics
or qualities of the provider, and/or insufficient
communication time between the patient and
clinician. Some relate to patient’s personal
factors such as symptom persistence, lack
of understanding or nonacceptance of the
diagnosis or treatment, as well as psychological
factors, e.g. to obtain unnecessary prescription
medications for illicit use.21
 Chapter 35: Preventive Care Delivery: Barriers and Remedies 349

However, the fact is that, this complex Out-of-pocket Expenditure*

phenomenon of doctor shopping is detrimental
Healthcare, in India, is primarily financed
to the establishment of an effective doctor-
t h ro u g h o u t- o f-p o c k e t p ay m e n t s by
patient relationship, which is central to the
households. Many low and middle-income
provision of care by the doctor. It is most
countries also rely on out-of-pocket payments
disturbing to the physicians that they are never
to help finance health care. 23 Insurance
certain whom the patient may go to the next
schemes which cover only hospital expenses,
time he/she is ill.
like those being rolled out nationally in India,
Lack of continuity of health care is
will fail to adequately protect the poor against
associate with decreased patient and doctor
impoverishment due to spending on health—
satisfaction and may positively affect other
there being no reimbursement for preventive
health outcomes, such as adherence to
services.24
treatment, uptake of preventive services, and
increased hospitalizations, and emergency R e s u l t s s h o w t h a t o u t- o f -p o c k e t
admissions. expenditures create financial barriers to
accessing health services. Studies from India
Anxiety About Procedures and Possible provide evidence that out-of-pocket payment
Results for chronic conditions, even for outpatient
care, pushes people into poverty. 25 Households
The patient may have his own apprehensions that have difficulties paying medical bills may
regarding the effectiveness of various preventive delay or forgo needed health care. Patients
procedures. Patients may believe that they are do not see immediate benefits of paying for
likely to be exposed to the risk of adverse effects preventive consultation or investigations.
from the test. While this concern applies to Preventive services cost money, and while
all clinical practices, it is especially important they may yield on ultimate saving, few families
in relation to preventive services because the are readily inclined to spend for medical care
individuals who receive these interventions when they are not faced with definite illness.
are often healthy. Minor complications or rare
Out-of-pocket costs remain a barrier to
adverse effects that would be tolerated in the
use preventive health services for uninsured
treatment of a severe illness take on greater
population. Although financial protection
importance in the asymptomatic population
through public or private health insurance
and require careful evaluation to determine
substantially reduces the amount that people pay
whether benefits exceed risks. Further certain
directly for medical care, yet in some countries
screening procedures and tests are known to
the burden of out-of-pocket spending can still
give ‘false positive’ results, leading to further
create barriers to healthcare access and use.26
testing, which many not be cost effective, besides
causing unnecessary mental and physical harm
The Doctor
to patients. Studies have reported that false-
positive mammography results, coupled with Several studies have explored physicians’
reports that women’s physicians did not advise attitudes toward prevention and barriers to
regular screening, could lead to non-adherence the delivery of preventive health interventions.
to future screening.22 Participants in such studies saw preventive
*Out-of-Pocket medical expenditure could be payments toward doctor’s fees, medicine, diagnostics,
operations, charges for blood, ambulance services, etc. while non-medical expenditure include money
spent toward travelling expenses, lodging charges of escort, attendant charges, etc.

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 350  Section 8: Prevention and Health Care
care as legitimate in family practice when it
was associated with concrete action or a test,
but rated their physicians as poor at delivering
prevention. Collectively, these studies have
identified the following physician’s barriers
that hinder a wide variety of preventive care.27,28
Lack of Training
Physicians are generally not geared to health
promotion because of ‘inadequacies’ of the
present medical education, which is hospital
based and disease oriented. The present curative
healthcare system ignores the integral aspects
of health promotion and disease prevention.
Because attention to health promotion and
disease prevention can contribute greatly to
reducing costs, improving health outcomes,
and enhancing patient satisfaction, it will be
essential for physicians to be skilled at helping
patients maximize their health and prevent
illness. This calls for the redesigning of medical
education system to cater for the health needs
of the population. In a study reported in BMJ,
the author Tamblyn R, et al states, “Transition
to a community oriented problem based
learning curriculum is associated with significant
improvements in preventive care and continuity
of care and an improvement in indicators of
diagnostic performance”.29
Lack of Clear Guidelines for the Local
Population
The major goal of clinical guidelines is to
maximize benefits to patients with specific
diseases by encouraging standardization among
healthcare providers. However, guideline
multiplicity is an important problem in clinical
decision-making. Some physicians may perceive
specific guidelines as more influential than other
guidelines; some may favour multiple guidelines,
whereas others may follow conservative
guideline combinations.
Too many guidelines may also cause
confusion among some doctors. For example,
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several medical journals publish viewpoints
and counter-viewpoints supporting or opposing
a wider utilization of statins for primary
prevention. The upper limit of desirable total
cholesterol level in the local healthy population
and for those with other co-morbid diseases like
diabetics, renal and hepatic impairment vary
from guidelines issued by the Adult Treatment
Panel III (ATP III) of the National Cholesterol
Education Program; the National Institute for
Health and Clinical Excellence (NICE), and
the American Heart Association and American
College of Cardiology Foundation. Further,
although the benefits of detecting and treating
dyslipidaemia in patients with known CVD is
clear, controversy remains regarding screening
asymptomatic individuals who are not known
to be at increased cardiovascular risk.30
Besides, physicians’ intrinsic attributes may
be possible barriers to implement guidelines in
their clinical practice (Table 35.2).
All such issues require local experts to
provide clear consensus guidelines rather than
relying on other countries for the information.
The Royal Australian College of GPs states in its
position paper that clinical guidelines should
be developed by “practicing clinicians in such a
Table 35.2  Physician’s barriers to using guidelines***
Physician attribute Barriers
Knowledge Lack of awareness
Lack of familiarity
Attitudes Lack of agreement
Lack of self-efficacy*
Lack of outcome expectancy**
Inertia of previous practice
Behavior External barriers
Patient related barriers
Environmental related barriers
Guideline related barriers
*Lack of self-efficacy: Self-efficacy is the belief that one can
perform a task.
**Lack of outcome expectancy: Outcome expectancy is the
belief that if one carries out
a task it will make a difference to patient outcomes.
***Bruce Arroll Why are guidelines not used and what can be
done to change that?
NZFP, Volume 30 Number 5, October 2003.
 Chapter 35: Preventive Care Delivery: Barriers and Remedies 351
way as to provide useful assistance in practical
settings rather than a “recipe” for invention.”31
Lack of Confidence
As observed earlier, multiple, bulky, paper
manuals, which have insufficient access at the
point of care and difficult to implement to the
local population at risk, create an academic
barrier for physicians to familiarize with the
outcomes of guidelines.
Many physicians are sceptical of the
evidence behind new recommendation
because in their judgment they may be
compromised by bias.32 This is especially true
when medical device and pharmaceutical
companies or professional societies are
involved in guideline development.33
As a result, some doctors do not provide
any evidence based prevention as they do not
perceive any benefits of such practice. This may
be due to the fact that preventive measures often
do not provide immediate results.
Communication Skills*
The skill in communication is central to all
forms of preventive care. It needs special
skills to convince, particularly asymptomatic
individuals to agree to preventive measures.
Unrealistic Targets
Some harmful addictive behaviors, such as
smoking, alcoholism and drug abuse take
considerable time and perseverance to resolve.
For example, the average success quit rate for
smokers per year is just 5–10%. This is possible
only after a year of persistent motivation and
health education by the doctor. Research is clear
that most people who try to stop smoking relapse
a number of times before finally succeeding—
*Ref. Chapter 10 Communication skills.
**Populations at risk may be defined broadly, including but not limited to the poor, frail, disabled,
economically disadvantaged, homeless, racial and ethnic minorities, persons with low literacy, victims
of abuse or persecution, and persons with social risk factors such as isolation.
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and most in the first three months after quitting.34
If doctors set an unrealistic barrier in terms of
time duration or outcome for themselves for
an individual’s quit attempts, and give up their
counseling, medication reinforcement, and
other supportive therapy altogether after a short
period of trail, they fail to achieve the target.
The Payment System
These factors include inadequate reimbursement
for preventive services. Financial incentives to
health care professionals appear to be strong
drivers to promote preventive services. Survey
data show that significant increase in ‘pay for
performance’ incentives may accelerate the
adoption of guidelines, and that small rewards
will not motivate doctors to change their
preventive care routines.35
Solutions to Barriers
First, family physicians should be made
aware of their great contributions to health
promotion by e.g. providing information to
their patients on health promoting as well
as harmful behaviors. The doctor-patient
relationship provides profound knowledge to
the complex health issues of the patients and
their family members to family physicians,
and their advice facilitates to overcome
barriers that present in the process of disease
prevention and health education.36,37
While physician’s preventive advice and
activities traditionally have been directed at
the individual patient and family, interventions
aimed at community populations are becoming
more important. The detrimental health
behavior of many individuals and unhealthy life
style in the ‘population at risk’** has precipitated
significant risk to many noncommunicable and
 352  Section 8: Prevention and Health Care
infectitious diseases. It is the responsibility of
physicians, by joining with others in public
health campaigns, to maintain population at risk
patients’ as healthy as possible and preventive
care is one of the essential ingredients in
achieving this goal.38, 39
Lifestyle habits such as smoking, abuse
of alcohol and drugs, sedentary habits and
unhealthy food habits which have developed
over many years, can be very difficult to
change even when the individual is well
motivated. There are a variety of instructional
motivational and behavioral techniques
available,40 which include general information
about the approach, as well as links, training
resources, and information on reprints and
recent research and can be used to initiate a
lifestyle change programme. Family physicians
should be aware of such resources and use
them in collaboration with multidisciplinary
team to give support and to motivate people
who find behavior modification difficult.
Successful preventive practice will certainly
demand more time and skills from physicians.
There is also an urgent need to reduce the
patient load for doctors in both the public
and private practices. These objectives can
be achieved to a great extent when physicians
work closely with other health professionals in
organized health care centers for better results.
In some countries such as the United Kingdom,
“nurse facilitators” are appointed, whose job is
to help family physicians and primary health
care teams extend preventive medicine in
family practice.41 “Health promotion clinics”
are successfully functioning under authority
of National Health Services in UK, wherein
clearly defined protocols and guidelines are
provided for family physicians with respect to
preventive services.42
Providing comprehensive, clear and
agreed guidelines should be made available,
especially applicable to local population.
The “Handbook for Putting Prevention into
Practice”— published by office of Disease
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Prevention and Health Promotion, US.
Preventive Service Task Force, is very useful
to follow and the recommendations therein
can be suitably molded to suit local need.43
Care should be taken to keep a sense of
priorities when investigations and screening
procedures are planned. Unnecessary
interventions, provoking much anxiety,
should be kept to a minimum. Unnecessary
anxiety can result from false positive results
and depression from untreatable conditions.
Thus, we need to demonstrate and ensure that
screenings are done rationally.
Display of posters in waiting rooms to
remind patients to avail preventive services
and to encourage patients to ask about
preventive services, providing flow chart
sheets (e.g. adult/childhood immunization);
patient reminder postcards for continuity
of preventive services and preventive care
timetable posters to remind physicians, office
staff and patients when preventive care is
recommended are very helpful in health
education and disease prevention.
In the wider community context, the
government and its health agencies should
provide education to the public on the need to
have a regular “family doctor” for every family
and individual so that continuity of care is
provided to facilitate the practice of preventive
care. On the other hand family physicians must
realize that, it’s not only their professional ,
but also ‘cultural’ competency (Table 35.3).44
is of importance, without which it is not easy
to change patient’s health belief model and
it can only be achieved over a long period of
time with the combined effort from individual
doctors and public health agencies.
Conclusion
Advances in medicine offer unprecedented
opportunities to improve health; yet, globally
the leading causes of morbidity and mortality
are intimately linked to preventable factors
 Chapter 35: Preventive Care Delivery: Barriers and Remedies 353
Table 35.3 Strategies for working with patients in
cross-cultural settings
• Learn about the cultural traditions of the patients
you care for
• Pay close attention to body language, lack of
response, or expressions of anxiety that may
signal that the patient or family is in conflict but
perhaps hesitant to tell you
• Ask the patient and family open-ended questions
to gain more information about their assumptions
and expectations
• Remain nonjudgmental when given information
that reflects values that differ from yours
• Follow the advice given by patients about
appropriate ways to facilitate communication
within families and between families and other
health care providers
Source: Mc Laughlin L, Braun K. “Asian and Pacific
Islander cultural values: Considerations for health
care decision-making.” Health and Social Work.
1998;23(2):116–126.
such as smoking, malnutrition, alcohol misuse,
lack of exercise, and maladaptive behaviors.
Compelling evidence indicates that
reducing risk factors yields substantial overall
health benefits and saves lives. Although
preventive efforts can be applied effectively at
many points in a disease process, a number of
barriers may interfere. These include physician
education and attitudes; patient education,
expectations, and motivations; and aspects of
the healthcare delivery system itself, such as
access and reimbursement.
In order to incorporate the benefits of
prevention into medical practice, some of
these barriers can be resolved with added
initiative from colleagues, coupled with
support from the government and cooperation
from patients.
Key Messages
™™ The majority of noncommunicable diseases
can be averted through interventions and
policies that reduce major risk factors.
™™ Many preventive measures are cost-
effective, including for low-income
countries.
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™™ Some preventive actions can have a quick
impact on the burden of disease at the
population level.
™™ Interventions that combine a range of
evidence-based approaches have better
results.
™™ Comprehensive prevention strategies
must emphasize the need for sustained
interventions over time.
References
1. WHO. Noncommunicable diseases. Fact sheet,
Updated March 2013. Web site: http://www.
who.int/mediacentre/factsheets/fs355/en/;
http://www.afro.who.int/en/clusters-a-
programmes/dpc/non-communicable-
dis eas es-managementndm/over view/
policies-and-strategies.html(Accessed on
11-07-2013).
2. WHO. Noncommunicable diseases. Fact sheet,
Updated March 2013. Web site: http://www.
who.int/mediacentre/factsheets/fs355/en/;
http://www.afro.who.int/en/clusters-a-
programmes/dpc/non-communicable-diseases-
managementndm/overview/policies-and-
strategies.html(Accessed on 11-07-2013).
3. Dickey LL et al. Primary care physicians’ use of
office resources in the provision of preventive
care. Arch Fam Med, 1996;5:399–404.
4. Lam Tai-pong. What is stopping GPs practicing
prevention? Hong Kong Practitioner, 1993;
15(8):2738–40.
5. Ben Fong. Preventive Care – are we doing
enough? Hong Kong Practitioner, 1992;14 (8):
2191–3.
6. Wechsler Henry. The Physician’s role in health
Promotion Revisited – A survey of Primary Care
Practitioners. NEJM, 1996;334(15):996–8.
7. Goodwin MA, et al. A clinical trial of tailored office
systems for preventive service delivery. The Study
to Enhance Prevention by Understanding Practice
(STEP-UP). Am J Prev Med, 2001;21(1):20–8.
[PMID: 11418253: Abstract].
8. Brauer PM, et al. Patient reports of lifestyle
advice in primary care. Can J Diet Pract Res, 2012
Fall;73(3):122–7. [PMID: 22958629: Abstract].
 354  Section 8: Prevention and Health Care
9. Stange KC, et al. Direct observation of rates
of preventive service delivery in community
family practice. Prev Med, 2000;31(2 Pt 1):167–
76. [PMID: 10938218: Abstract].
10. Lau JS, et al. Receipt of preventive health services
in young adults. J Adolesc Health, 2013;52(1):42–
9. doi: 10.1016/j. jadohealth. 2012.04.017. Epub
2012 Jul 6.[PMID: 23260833: Abstract].
11. US Preventive Service Task Force. Guide
to Clinical Preventive Services. 2nd ed.
Washington DC. 1996.
12. Yarnall KS, et al. Primary care: is there enough
time for prevention? Am J Public Health, 2003;
93(4):635–41. [PMID: 12660210: Free PMC
Article].
13. Pollak KI, Estimated time spent on preventive
services by primary care physicians. BMC
Health Serv Res. 2008 Dec 1; 8:245. doi:
10.1186/1472-6963-8-245.[PMID:19046443:
Free PMC Article].
14. Betancourt JR. Eliminating racial and ethnic
disparities in health care: what is the role
of academic medicine? Acad Med, 2006;
81(9):788–92. [PMID: 16936481: Abstract].
15. Betancourt JR, et al. The Institute of Medicine
report “Unequal Treatment”: implications for
academic health centers. Mt Sinai J Med, 2004;
71(5):314–21. [PMID: 15543432: Abstract].
16. Tobacco Free Initiative Meeting on Tobacco
and Religion, Geneva, Switzerland, 3 May 1999.
Report. Geneva: World Health Organization;
1999. WHO document WHO/NCD/TFI/99.12
17. Koenig HG, et al. The relationship between
religious activities and cigarette smoking
in older adults. J Gerontol A Biol Sci Med
Sci, 1998;53(6):M426–34. [PMID: 9823746:
Abstract].
18. Flores G. Culture and the patient-physician
relationship: Achieving cultural competency
in health care. J Pediatr, 2000;136(1):14–23.
19. Cherutich P, et al. Lack of knowledge of HIV
status a major barrier to HIV prevention,
care and treatment efforts in Kenya: results
from a nationally representative study. PLoS
One. 2012;7(5):e36797. doi: 10.1371/journal.
pone.0036797. Epub 2012 May 4. [PMID:
22574226: Free PMC Article].
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20. Sansone RA, et al. Doctor Shopping: A
Phenomenon of Many Themes. Innov Clin
Neurosci, 2012;9(11-12):42–46. [PMID:
23346518: Free PMC Article].
21. Kasteler J, et al. Issues underlying prevalence
of “doctor-shopping” behavior. J Health Soc
Behav, 1976;17(4):329–39. [PMID: 1010914:
Abstract].
22. DeFrank JT, et al. Influence of false-positive
mammography results on subsequent
screening: do physician recommendations
buffer negative effects? J Med Screen,
2012;19(1):35–41. doi: 10.1258/jms. 2012.
011123.[PMID:22438505:Abstract].
23. Reddy SR, et al. Health care payments in the
asia pacific: validation of five survey measures
of economic burden. Int J Equity Health, 2013;
12(1):49. [PMID: 23822552: Free Article].
24. Shahrawat R, et al. Insured yet vulnerable: out-
of-pocket payments and India’s poor. Health
Policy Plan, 2012;27(3):213–21. doi: 10.1093/
heapol/czr029. Epub 2011 Apr 12. [PMID:
21486910: Free Article].
25. Bhojani U, et al. Out-of-pocket healthcare
payments on chronic conditions impoverish
urban poor in Bangalore, India. BMC Public
Health, 2012;12:990. doi: 10.1186/1471-2458-
12-990.[PMID: 23158475: Free PMC Article].
26. Hoffman, et al., 2005; May and Cunningham,
In Banthin et al., 2008
27. Cornuz J, et al. Physicians’ attitudes towards
prevention: importance of intervention-
specific barriers and physicians’ health
habits. Fam Pract, 2000;17(6):535–40. [PMID:
11120727: Free Article].
28. Mazza D, et al. General practice and
preventive health care: a view through the
eyes of community members. Med J Aust, 2011;
195(4):180–3. [PMID: 21843119: Abstract].
29. Tamblyn R, et al. Effect of a community
oriented problem based learning curriculum
on quality of primary care delivered by
graduates: historical cohort comparison study.
BMJ, 2005 Oct 29; 331(7523):1002. Epub 2005
Oct 20. [PMID: 16239292: Free PMC Article].
30. Bell DA, et al. Screening for lipid disorders.
Pathology, 2012;44(2):115–21. doi: 10.1097/
PAT.0b013e32834f90fe. [PMID: 22198257:
Abstract].
 Chapter 35: Preventive Care Delivery: Barriers and Remedies 355
31. RACGP – Position on evidence based medicine
– December 1998.
32. Lenzer J. Why we can’t trust clinical guidelines.
BMJ. 2013;346:f3830. doi: 10.1136/bmj.f3830.
[PMID:23771225].
33. Abramson J, et al.The effect of conflict of
interest on biomedical research and clinical
practice guidelines: can we trust the evidence
in evidence-based medicine? Ambulatory
Care and Prevention, Harvard Medical School,
Cambridge, MA, USA [PMID: 16148253: Free
full text].
34. How Smokers Are Quitting: The Wisconsin
Tobacco Survey.
We b s i t e : h t t p : / / w w w . c t r i . w i s c . e d u /
Publications/publications/HowSmokersQuit.
pdf b (Accessed on 16-07-2013).
35. Town R, et al. Economic incentives and
physicians’ delivery of preventive care: a
systematic review. Am J Prev Med, 2005;
28(2):234–40. [PMID: 15710282: Abstract].
36. Demak MM, et al. The doctor-patient
relationship and counseling for preventive
care. Patient Educ Couns, 1987;9(1):5–24.
[PMID: 10301559: Abstract].
37. Thakur NM, et al. Prevention in adulthood:
forging a doctor-patient partnership. Prim
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Care, 2002;29(3):571–82. [PMID: 12529898:
Abstract].
38. Shavers VL, et al. Barriers to racial/ethnic
minority application and competition for NIH
research funding. J Natl Med Assoc. 2005;
97(8):1063–77. [PMID: 16173321: Free PMC
Article].
39. Chin MH. Populations at risk: a critical need
for research, funding, and action. J Gen Intern
Med, 2005;20(5):448–9. No abstract available.
[PMID: 15963170: Free PMC Article].
40. Web site: http://www.motivationalinterviewing.
org/#sthash.4hbYjJAZ.dpuf (Accessed on 17-07-
2013).
41. Fullard E et al. Facilitating prevention in
primary care. BMJ, 1984;289:1585–7.
42. Davies BM, Davie Tom. Community Health,
Preventive Medicine and Social Services. 6th
ed. 1993: 29.
43. Web site: http://www.ahrq.gov/professionals/
clinicians-providers/guidelines-
recommendations/uspstf/index.html (Accessed
on 18-07-13).
44. Web site: http://www.euromedinfo.eu/
how-culture-influences-health-beliefs.html/
(Accessed on 18-07-2013).
 9
Section

Education and Research

™™ Clinical Audit
™™ Evidence-based Medicine: Principles
™™ Evidence-based Medicine: Practice
™™ Research in Family Medicine

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 36 Clinical Audit

“Knowledge advances not by repeating known facts, but by refuting false dogmas.”
Karl Popper

Introduction has caused harm to patients. The point has

The audit of medical practice, i.e. quality of
medical care and the process of its delivery
against prescribed standards of care to patients
is neither a new concept nor a new activity.*
From earlier days all good doctors and other
health care providers have always attempted to
improve the care they provide for their patients
by periodically assessing their work. Studies
have shown that from ancient times physicians
have at least on occasion been driven to seek
the consent of their patient either because of
respect for the patient’s autonomy or from fear
of the consequences of their failure.1 It has been
realized that the effective and safe practice of
medicine by physicians can be achieved by
analyzing their clinical outcomes, such as quality
of care, morbidity and mortality periodically.
However, notwithstanding the good quality
health care delivery, the subject of medical
audit has been a matter of in depth discussion
and debate at various government, consumer,
medical media and other lay bodies. There are
documented reports wherein departure from
accepted standards of medical care, health care,
or safety on the part of health care providers
been that the medical profession should be
made answerable for the standard of their own
treatment—the main object of an audit being
to maintain or improve the medical standards.
Therefore, hospital administrators, medical
staff and medical associations including family
physicians have come to view medical audit with
increasing concern.
Definition
The generally understood concept of an ‘audit’
is an unbiased examination and evaluation
of the financial statements of a business
organization. It’s a retrospective analysis of
credit and debit in a business and provides
formulation of a prospective plan to achieve
greater work efficiency by cost-effective
management in the following year. Audit in
medical practice should be viewed in a similar
fashion as a positive retrospective analysis
to further improve prospective standards of
healthcare delivery system.
There are few terms which can be confusing
but which illustrate the way the audit has been
understood in medical practice:

*Clinical audit has a history stretching back to the work of Florence Nightingale (1800s) and US Physician,
Ernest Codman (early 1900s). Both Nightingale and Codman monitored mortality and morbidity rates in
their respective institutions. Nightingale used an epidemiological method of review, monitoring rates of
nosocomial infections in relation to standards of hygiene. Codman established a plan to enable the tracking
of patient treatment outcomes as a way to identify clinical misadventures.

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 360  Section 9: Education and Research
Medical audit is defined as the review of the
clinical care of patients by medical staff only,
i.e. ‘uni-professional’ audit.
Clinical audit is the review of the activities
of all aspects of clinical care of patients by
medical and paramedical staff, i.e. ‘multi-
professional’ audit.
The current accepted definition of ‘clinical
audit’ appears in Principles for Best Practice in
Clinical Audit (2002) and was endorsed by the
National Institute of Clinical Excellence is:
“Clinical audit is a quality improvement
process that seeks to improve patient care
and outcomes through systematic review
of care against explicit criteria and the
implementation of change. Aspects of the
structure, process and outcome of care are
selected and systematically evaluated against
explicit criteria. Where indicated changes are
implemented at an individual, team, or service
level and further monitoring is used to confirm
improvement in healthcare delivery”.
Clinical audit is essentially all about
checking whether best practice is being followed
and making improvements if there are shortfalls
in the delivery of care. A good clinical audit will
identify (or confirm) problems and should lead
to effective changes being implemented that
result in improved patient care.
Clinical audit is the review of clinical
performance—the refining of clinical practice
and the measurement of performance against
agreed standards—a cyclical process of
improving the quality of clinical case.
Why is Clinical Audit Important?2
There are a number of reasons why clinical
audit is an important activity. The main reason
is that it helps to improve the quality of the
service being offered to users. Without some
form of clinical audit, it is very difficult to know
whether clinicians are practicing effectively,
and even more difficult to demonstrate this to
others. The benefits of clinical audit are that it:
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™™ Identifies and promotes good practice
and can lead to improvements in service
delivery and outcomes for users.
™™ Can provide the information you need to
show others that your service is effective
(and cost-effective) and thus ensure its
development.
™™ Provides opportunities for training and
education
™™ Helps to ensure better use of resources and,
therefore, increased efficiency
™™ Can improve working relationships,
communication and liaison between
staff, staff and service users, and between
agencies.
Generally, the audit demonstrates evidence
of one of the following:
™™ Benefit to patient care
™™ Benefit to health care professionals
™™ Benefit to the specific sub-specialty, e.g.
primary care
™™ Continuing high quality of pathology
service
™™ Deterioration in health delivery system
™™ Continuing underperforming health care
services
™™ Deterioration in patient care.
Different Between Medical and
Clinical Audit
In the practice of family medicine, “medical
audit” has moved to become “Clinical audit”,
because other practitioner groups’ and
managerial staff involvement is essential to
quality improvement.
Audits conducted by doctors are often
referred to as ‘medical audits’, although the
term ‘clinical audits’ could also be used. It
is important to stress that very few health
care procedures involve just one medical
discipline and that non-medical staff such as
receptionists, secretaries, managers and social
workers also play a vital role in the quality of
services provided. Clinical audit therefore,
 Chapter 36: Clinical Audit 361

is usually a multi-disciplinary activity. Many In simple terms, research potentially

clinical audits are also ‘multi-sectoral’, i.e. discovers the right thing to do, whereas audits
they usually involve health and social services, look at whether or not the right thing is being
acute care providers, education and similar done.
health event organizations. Key differences between clinical audit
Thus, ‘clinical audit’ term is used to cover and research are outlined in table below
wider perspective for any audit conducted by (Table 36.1).
professional in a health care system.
The Audit Cycle (Fig. 36.1)
Multiprofessional Clinical Audit in Clinical Audit is directly related to improving
Family Practice services against a standard that has already
been set by examining.
The aim of clinical audit in family practice is 1. Whether or not what ought to be happening
two-fold: firstly, to improve the quality of care is happening.
being given to patients; and secondly, motivating 2. Whether current practice meets required
the staff in the practicing team to analyze standards.
periodically what is being done and achieved. 3. Whether current practice follows published
However, because family practice being the guidelines.
initial referral point for the majority to receive 4. Whether clinical practice is applying the
care, the relationship between all members of knowledge that has been gained through
the practice team and the patient is always very research.
important in the evaluation of medical audit.
Table 36.1 Main differences between clinical audit
Therefore, medical audit in family practice and research
must not only concern itself with the quality
Clinical audit Research
of clinical care (diagnosis and treatment), but
Based on facts Based on hypotheses;
also encompass all practical factors which may
(standards) creates new knowledge
encourage or deter any patient from seeking help
Each patient receives May involve
in the practice team; e.g. the timely availability the same care randomization into
of not just the physician, but also the other different treatment
office staff to any patient. Clinical audit should, groups, including
placebos
therefore, include actively all members of the
practice team—family doctor, practice manager, Informed consent might Informed consent
be required always required
nurses and receptionists.3
Results usually apply to Results are often
the local population generalizable, i.e.
Difference Between Clinical Audit they may influence
widespread clinical
and Research practice
“Research is concerned with discovering the Methodology is less Rigorous methodology
right thing to do; audit with ensuring that it is stringent than in and extensive statistical
done right” (BMA Clinical Audit Committee). research analysis
Typically do not require Always require ethical
For example, research might ask: “What is the
ethics approval, but approval from the
most effective way of treating pressure sores?” should abide by an local or national ethics
Audit would then ask: “How are we treating ethical framework committee
pressure sores and how does this compare with Source: Farah Janmohamed. student BMJ. 2006;14:1-44
accepted best practice?” January ISSN 0966-6494

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 362  Section 9: Education and Research
Fig. 36.1  The aduit cycle
5. Whether current evidence is being applied
in a given situation.
Who should Participate?
Any member of the multi-disciplinary team
providing care to patients may participate in
clinical audit. This includes managerial as well
as clinical staff.
Ethical Issues*
Clinical audit, as defined previously, does
not require approval by a Research Ethics
Committee, but it may raise ethical issues.
For example:
™™ Sharing of patient data with another
healthcare organization
™™ Surveying patients about sensitive issues
The process of registering the audit with
State ethical committee will ensure that any
ethical issues are identified at an early stage.
Steps in Clinical Audit in Any
Particular General Practice**
Following are the well-tried stages in clinical
audit in a general/family practice (Fig. 36.2).
Identifying Problems—Choosing a
Topic
The reason for undertaking the audit may
arise from a problem that may be identified
from every day practice, medicolegal cases,
or practice guidelines (e.g. Joint National
Committee on Detection, Evaluation, and
*Although clinical audit evaluation does not require approval from a research ethics committee, it is
mandatory that “the dignity, rights, safety and well-being of participants must be the primary consideration”.
**Ref. “A Basic Guide to Clinical Guide at Kingston Hospital NHS Trust”
Web site: http://education.kingstonhospital.nhs.uk/documents/clinical_audit_/A_Basic_Guide_to_Clinical_
Audit
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Treatment of High Blood Pressure) that people
know or feel practice could be improved upon.
Choose a topic that is considered to be
important or significant. These cover a wide
range, such as: whether patients can easily
obtain help (accessibility); non-attendance
when patients fail to return (for immunization,
various follow-up examination); whether
certain methods of diagnosis produce results
(HbA1c levels in diabetic patients); and
why some treatments do not work properly
(antihypertensive drugs and resistant
hypertension).
Choosing an interesting topic is crucial
in maintaining motivation and interest
throughout the audit. Interested team
members are more likely to attend meetings,
willing to put in a little extra time, which
audit invariably requires. A topic will only be
interesting if it deals with an acknowledged
problem, preferably related to the local set up.
There is no point in auditing something that
has already been done well.
The topic should not aim just to provide
better care but also more efficient care, i.e.
how the results may reduce the time we spend
on much seemingly unproductive work. Audit
ideas can be taken from:
™™ National guidelines
™™ NICE guidelines
™™ Patient management
™™ Compliance
™™ Patient complaint
™™ Adverse drug incidents

Fig. 36.2  Steps in audit cycle
™™ Areas of high volume, high risk, high cost
when improvements can be made, e.g.
serious accidents, new service that needs
to be assessed.
Agree Criteria—Consult, Involve
‘Appropriate’ Others
Keep the data collection forms as simple as
possible. Speak to others who have audit
experience before starting. Discuss plan with
relevant groups, e.g. other professionals who
care for the patient group being audited;
other departments involved in the care, e.g.
accident and emergency faculty, diagnostics;
administrative staff managers and patients. It
is good practice to engage service users in the
audit process, especially if you are auditing
patient experience.
Discussing with others who have done audits
will have two advantages—first the problems that
others had with their audits and the measures
they took to solve them will be valuable; second,
the data from others can be used comparison
with your practice. If such comparison is
contemplated, sampling, inclusion and exclusion
criteria have to be similar.
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Chapter 36: Clinical Audit 363
Setting Priorities
In any health practice, it is rarely possible to
correct immediately all problems, so some
system of priorities have to be worked out. To
help yourself priorities, ask yourself:
™™ Is the problem common?
™™ Does it have serious consequences?
™™ Can I do something about it?
Set Standards for Achievement—
Criteria (i.e. What should be Happening)
An audit criterion is a ‘specific, evidence based
statement’ of what should be happening?—e.g.
all asthmatics should have had a peak flow (PF)
recorded in the past year. It should be easily
measurable or quantified—e.g. ‘asthmatics
should have had a PF recorded in the past
year’. Do not try to audit too many criteria at
once—one or two will be just enough.
Agree Criteria (Data to be Collected
and Analysed (i.e. What is Happening)
One has to collect data for audit from various
sources.
 364  Section 9: Education and Research
You can collect information from:
™™ Computer registers
™™ Review of contents of medical records
™™ Questionnaires—patients, staff and doctors
™™ Date collection sheets.
You can delegate this responsibility to all
the office staff who can help you set up the
search or organize questionnaires.
Identify Areas of Improvement and
Setting of Standards
This stage can be difficult and time consuming.
Adequate standards can only be achieved after
much study and consultation, not only between
members of the practice team but with other
physicians and comparison with standards
recommended by parent organizations or those
laid down in the contract.
An audit standard is a minimum level of
acceptable performance for that criterion. For
example, at least 60% of asthmatics should
have PF recorded in the past year. Some criteria
are so important that they need 100% standard.
However 100% standards are unusual—
patients or circumstances prevailing prevent
perfection, which is reflected in the ultimate
results obtained. For Example:
Criteria Standard Results
Asthmatics should have PF Minimum 40%
meter recorded once a year 60%
All patients should be seen Minimum 45%
within 15 minutes of their 70%
appointment
All drug allergy patients Minimum 95%
listed on computer as 100%
‘active problem’
All eligible women aged Minimum 50%
30–65 years should have 75%
pap smear once a year
Pilot Audit—Make Changes, Evaluate
Information
This is a stage of ‘performance versus targets’.
Is our performance in line with our targets? We
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need to compare our data with earlier defined
targets within our practice or with similar
practices and provide feedback.
If targets have not reached, we need to work
out possible reasons why the practice hasn’t
met the standard we have set. Some common
reasons are:
Practice • Failing to feed exact ‘code’ on
reasons computer
• Failing to feed information on the
spot (delay tactics)
• Failing to delegate responsibility
(not my job)
Patient • Refusing to have tests done
reasons • Absent on appointment day/time
(holidaying)
Doctor • Not all physicians are aware of the
reasons practice policy
• Not all partners agreed with the
policy
• Lack of ‘statistical’ knowledge
Re-pilot—Implement Changes (Repeat
the Cycle when Changes are Needed)
Above evaluation shows what changes need
to be done. Find new methods to correct any
deficiencies and alternative practice styles.
Repeat the cycle, i.e. reevaluate care to ensure
that any remedial action has been effective.
Re-audit
This is the final stage of further assessment to
check whether the corrective action has been
successful in remedying any deficiencies.
At the same time, a quick evaluation should
take place to make certain the problem is
unlikely to recur.
Keep a Record
Keep brief written record of—
™™ The reason for doing the audit
™™ Criteria and standards
™™ Results
™™ Plans for change
™™ Action taken
™™ When/whether to repeat the audit.

Confidentiality
In all stages of any audit, maintaining
confidentiality is very important.
Because all audit is examining performance
in practice, suspicion and uncertainty are
bound to arise and deter some physicians
from involving themselves too actively. It is
therefore essential that audits be designed
to create a positive force to help physicians
enhance their performance rather than to
inspect and find faults.
Audit—Pitfalls
Audit may:
™™ Be seen as a threat
™™ Be seen as an unpleasant time consuming
distraction from day-to-day practice
™™ Antagonize if introduced in an insensitive
way
™™ Give the impression of implied criticism.
Audit must:
™™ Assist staff
™™ Be effective at improving care
™™ Not be a menace or a means of discipline
™™ Have a clear purpose
™™ Use the no-blame approach
™™ Respect the individual skills of staff
™™ Crete an atmosphere in which mistakes can
be admitted without blame
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Chapter 36: Clinical Audit 365
™™ Audit in the right atmosphere—‘aims to
encourage, foster and maintain highest
standard in family practice’.
Conclusion
Clinical audit has become a key activity for
healthcare organizations. The clinical audit
process is frequently described as a cycle
of steps and gives a clear checklist of the
components required to undertake an audit
project successfully; however, it also requires
the creation of a supportive environment. The
identification of explicit audit criteria is the
core feature of any systemic approach to audit.
Adequate clinical contact and referral systems
are also very essential. The resources should
be cheap and simple and cause minimal
disturbance to clinical work. Implementing
changes is the most challenging stage in the
audit cycle.
Refrences
1. Dalla-Vorgia P, et al. Is consent in medicine a
concept only of modern times? J Med Ethics.
2001;27(1):59–61. [PMID: 11233382: Free PMC
Article].
2. Clinical audit: what it is and what it isn’t.
W e b s i t e : w w w . r c p s y c h . a c . u k / p d f /
clinauditchap1.pdf (Accessed on 26-07-13).
3. Chambers R, et al. Audit activity and quality
of completed audit projects in primary care in
Staffordshire. Qual Health Care. 1995; 4(3):178–
83. [PMID: 10153426: Free PMC Article].
 37 Evidence-based
medicine: PRINCIPLES

“The absence of evidence is no evidence of absence.”

A Case Scenario investigations for viral fever in a child with

stable vital parameters had mostly negative
A 2-month-old infant was brought to a rural
findings for more serious problems.2 However,
health center at 11.00 pm with a temperature
he could not substantiate the potential risks
of 104°F (i.e. 40°C). The child was in good
due to premature investigations (e.g. lumbar
health until 2 days previously when there was
puncture, doubtful treatment), with added
onset of intermittent fever to 104°F. There
anxiety that may arise due to both false positive
was no vomiting or lethargy. The vitals were
and false negative results, against benefits of
within normal limits. There was no rash or
‘wait-and-watch’ approach in such low-risk
neck rigidity or signs of dehydration. Systemic
infants, and re-examination of the infant after
examination was normal. The child was in
couple of hours for any deteriorating symptoms
good health all along, parents not having
and signs, versus emergency admission to
noticed anything abnormal with the child. The
the children’s hospital to investigate for any
family had no health insurance cover.
unusual sepsis etio-pathogenesis.3
The physician, who had seen similar illness
However, the parents contacted a
in infants and children in the recent past in his
pediatrician over the phone at the hospital,
rural surroundings, and had learnt through
who advised admission (also without
Centers for Disease Control and Prevention of
estimates of harms versus benefits). The
the prevailing influenza-like-illness with low
infant was rushed late night to the hospital.
morbidity and mortality, suspected an acute
The investigations were non-contributory,
viral febrile episode. He explained that it was
with added advice—“correlate clinically.” The
not reasonable to admit the febrile infant and
family acquired a sizable hospital bill (as the
do tests to all of them or start empiric antibiotic
family had no insurance cover); the child was
therapy,1 and advised close follow up. But
discharged with symptomatic treatment 2 days
parents could not be convinced of the possible
later with further uneventful recovery.4,5
benign nature of the child’s illness, and desired
to know if the child was suffering from some
life-threatening condition such as pneumonia,
Case Study Continued
and opted referral for hospitalization. The physician later undertook a brief literature
The physician knew that the nearest network search, which showed that the risk
children’s hospital was about 100 km away, of bacterial meningitis and serious bacterial
which had emergency admission facilities, and infection are about 0.5% (1 in 200) and 1.5%
specialized investigations for sepsis diagnosis. respectively. 6 A practice guideline, based
He was also aware of the fact that most upon meta-analysis, has been formulated

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 Chapter 37: Evidence-based Medicine: Principles 367
for the management of infants with fever
without source (without localizing signs).7 This
guideline provides solid evidence supporting
“close ambulatory follow-up of low-risk infants”
(i.e. normal WBC counts, urinalysis and stool
examination). Interestingly enough, a later
study evaluated parent preferences for the
care of febrile infants without apparent source.
Parents were given a case scenario similar to
the case discussed above. They were informed
of the risks, outcomes and costs of close
ambulatory follow-up versus hospitalization
for lumber puncture and sepsis work-up. About
80% of the patents chose the ambulatory option
of less testing because of fewer painful tests
and procedures, lesser chances of unnecessary
antibiotics, and the assurance that re-evaluation
was available if the child failed to improve.8
In the case scenario discussed above,
evidence-based approaches could have
clarified harms versus benefits of hospital
admission for sepsis work-up and enabled
better informed partnership decision making
between the physician and the patents.
Learning of Evidence-based
Medicine (EBM)
The above case is a typical example of a common
clinical situation faced almost daily by family
physicians—how to quantity harms versus
benefits and counsel patients and families
about patient treatment options, when required
evidence is either unavailable or unknown,
especially when point-of-care decisions have
to be made in remote healthcare centers with
unique challenges such as scarcity of specialty
care and under-resourced infrastructure.
There is evidence concerning primary care
clinicians that EBM is not always relevant to
primary care and that undue emphasis placed
on it can lead to conflict with a clinician’s duty
of care and respect for patient autonomy.9
Further, developing the ability to access
information from the medical literature,
critically appraising it, and applying it to
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patient care requires skills that need to be
taught. Most practicing physicians are not
taught these skills in medical school.10
Therefore, in most cases, the clinician
usually relies on his/her clinical experience
and judgment, perhaps associated by the
advice of colleagues or consultants who
practice the same way.11
What is Evidence-based Medicine?
EBM is probably best understood as a decision-
making framework that facilitates complex
decisions across different and sometimes
conflicting groups. EBM enable clinicians
to “see” the difference between alternative
decisions that would be hard to ascertain
otherwise. It involves considering research
and other forms of evidence on a routine
basis when making health are decisions. Such
decisions include clinical decisions about
choice of treatment, test or risk management
for individual patients, as well as policy
decisions for groups and populations.
EBM comes under several names, some of
which are: clinical—practice guidelines directory,
standardized plans of care, clinical algorithms,
clinical policies and clinical pathways.
Distinguishing Features of Ebm
Physicians sometimes question the novelty of
EBM, noting that medicine has always been
‘evidence-based’. Indeed since the times of
Ancient Greece, physicians have engaged in
scientific study. The traditional medical practice
has always drawn upon research—evidence at
different times to form key decisions (Fig. 37.1).
What distinguished EBM from the traditional
application of evidence in medicine, however,
is the explicit linkage between formation of a
specific policy based on research evidence that
is comprehensive, critical and explicit.
Comprehensiveness is important to ensure
that all evidence is considered rather than
just those studies that support a particular
viewpoint or that reflect a selection bias.
 368  Section 9: Education and Research
Fig. 37.1  The sequence of traditional medical decision-making12
Critical appraisal is emphasized to examine
the strengths and weakness of the study design
so that judgments about evidence can be
linked to quality.
Explicitness gives transparency to evaluation,
allowing readers to understand the methods
used in the analysis, the strengths of the
evidence, the gaps that exist, and the rationale
for practice recommendations or policies,
whether evidence—or opinion based.
Where Did Ebm Come From?
The philosophical origin of EBM extends back
to mid 19th century in post-revolutionary
Paris. In the current era, the term EBM was
coined by clinicians and epidemiologist group
led by Gordon Guyatt, at McMaster University
in Ontario, Canada in 1988.13 It became known
worldwide during the 1990s. Its core idea—
that we should consider the effectiveness
and harms of different interventions before
implementing them, using reliable estimates of
benefit and harm was, of course, not new. Many
people worldwide had previously pioneered
many of the epidemiological and statistical
methods needed to perform EBM. One leader
who stands out was Archie Cochrane, who,
early on, championed the importance of
understanding the effectiveness and efficiency
of healthcare interventions—and the methods
for doing so.14 The McMaster group, in turn,
developed these methods into user-friendly
toolkits that clinicians could apply in real
time to patients, making them more widely
available for practical applications.
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The Rationale for Ebm—the
Paradigm Shift (Table 37.1)
For years, clinical decision-making was based
primarily on physician’s knowledge base and
expert opinion. Accountability was centered
on patient outcomes, with success determined
by meeting the agreed treatment goals. The
system of accountability to medical boards
or healthcare insurance companies was not
rigidly applied. State medical boards invariably
provided the “final” accountability; if at all the
patient sought legal action.
But in the last few decades the amount of
information concerning available treatment
and management options for many conditions
has increased exponentially. This development
has particular relevance for general practice
given the breadth of conditions managed.
Increased patient sophistication, brought
about largely by mass media coverage of
medical advances and by information
accessibility on the internet and its global
impact requires that physicians provide
evidence validating the treatments or testing
procedures they choose.
Soaring health care costs have prompted
government and healthcare insurance
companies to scrutinize the effectiveness and
appropriateness of health care service utilization.
The high cost of medical case, in terms of both
morbidity and expenditure, are driving the need
to base clinical decision making on standardized
guidelines that can help physicians provide the
best care to all patients at the lowest-cost to the
individual and to society.15
 Chapter 37: Evidence-based Medicine: Principles 369
Table 37.1  The paradigm shift occurring in modern medicine16
The former paradigm
• Observation from clinical experience is a valid
way of building and maintaining one’s knowledge
about patient prognosis, diagnostic tests and the
effectiveness of treatment
• Understanding of mechanism of disease and basic
pathophysiology principles are a sufficient guide for
clinical practice
• Combination of traditional medical knowledge and
experience is sufficient to allow one to evaluate and
adopt new medical interventions
• Content expertise and abundant clinical experience
are sufficient for generating valid guidelines for
clinical practice
• The focus is on traditional scientific authority and
adherence to standard approaches where answers
are often sought from direct contact with local and
international experts
Definition of EBM and EBP
There are a number of definitions of EBM or
Evidence-based practice (EBP). Below are
reproduced some of those that are sited most
commonly.
Evidence-based Medicine (EBM)17
EBM is the integration of best research evidence
with clinical expertise and patient values.
™™ ‘Best clinical evidence’ means clinically
relevant research, often from the basic
sciences of medicine, but especially from
patient centered clinical research into
the accuracy and precision of clinical
examination, diagnostic tests, the power
of prognostic markers, and the efficacy and
safety of therapeutic, rehabilitative, and
preventive regimens.
New evidence from clinical research
both invalidates previously accepted
diagnostic tests and treatments and
replaces them with new ones that are more
powerful, more accurate, more efficacious,
and safer.
™™ ‘Clinical expertise’ means the ability to use
our clinical skills and past experience to
rapidly identify each patient’s unique health
state and diagnosis, their individual risks and
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The new paradigm
• Clinical experience is crucial to become a competent
physician and attempts to systematically record
observations in a reproducible and unbiased fashion
can significantly increase one’s confidence about
his/her skills necessary for clinical practice
• The understanding of basic mechanisms of disease
is necessary but an inefficient guide for clinical
practice
• Understanding, specific rules regarding the quality
of evidence available is essential to correctly
interpret medical literature on new or existing
medical interventions
• In addition systematic and rigorous review and
evaluation of current scientific evidence is necessary
for making clinical guidelines recommendations
• Focus on independent assessment of evidence and
its implementation in clinical practice
benefits of potential interventions, and their
personal values and expectations.
™™ ‘Patient values’ means the unique
preferences, concerns and expectations each
patient brings to a clinical encounter and
which must be integrated into the clinical
decisions if they are to serve the patient.
When these three elements are integrated,
clinicians and patients form a diagnostic and
therapeutic alliance, which optimizes clinical
outcomes and quality of life.
Evidence-based Practice (EBP)18
“EBP is an approach to health care where in
health professionals use the best evidence
possible, i.e. the most appropriate information
available to make decisions for individual
patients. EBP values, enhances and builds
on clinical expertise, knowledge of disease
mechanisms, and patho-physiology. It involves
complex and conscientious decision-making
based not only on the available evidence but
also on patient characteristics, situations, and
preferences. It recognizes that health care is
individualized and ever changing and involves
uncertainties and probabilities. Ultimately EBP
is the formalization of the care process that the
best clinicians have practiced for generations.”
 370  Section 9: Education and Research
Steps to Practicing EBM19
(Fig. 37.2)
At the technical level, EBM involves converting
complex information from literally thousands
of individual studies into user friendly risk
estimates. It involves a defined five step
approach of:
1. Asking an answerable clinical question:
Defining a structured question(s) relevant
to clinical situation is the first step. A good
clinical question will have four major
elements considered: Patient, Intervention,
Comparison and Outcome, commonly
known as PICO. For example: in a 50-year-
old man with diabetes and no heart disease
(patient), does a statin (intervention)
compared to placebo (comparison) reduce
outcomes (CV events or mortality)?
Another example could be: In the case of a
50-year-old male (Patient) is Omega 3 fatty
acids (Intervention) as effective as Vitamin
E (Comparison) in treating cardiovascular
disease (Outcome)?
Different types of questions are best
answered by different types of studies
(Tables 37.2 and 37.3).
2. Search the literature for the best available
evidence.
This step requires a familiarity and some
skills in selecting accurate, appropriate cross-
referencing terms to provide useful literature
searches. Choosing sufficiently precise and
sensitive keywords help to identify studies
of relevance to selected question.
Online medical databases, such as MEDLINE
or Pub Med, are commonly used sources.
In the context of EBM, randomized clinical
trails (RCTs) are commonly regarded as
the ‘gold standard’ methodology to assess
the effectiveness of different forms of
interventions, although other methodologies,
such as cross-sectional studies, cohort
studies, case reports, expert opinions, peer
reviews, etc. are also evaluated.
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In many systemic reviews, studies are
assigned a ‘grade’ or ‘level’ of evidence that
reflects the strength of evidence. The US
Preventive Services Task Force (USPSTF)
grades the quality of the overall evidence
for a medical service on a 3‐point scale:20
Good
Evidence includes consistent results from
well designed, well‐conducted studies in
representative populations that directly assess
effects on health outcomes.
Fair
Evidence is sufficient to determine effects
on health outcomes, but the strength of the
evidence is limited by the number, quality,
or consistency of the individual studies,
generalizability to routine practice, or indirect
nature of the evidence on health outcomes.
Poor
Evidence is insufficient to assess the effects on
health outcomes because of limited number or
power of studies, important flaws in their design
or conduct, gaps in the chain of evidence, or lack
of information on important health outcomes.
Some examples of the way evidence ratings
will appear in the text of an article are:
™™ “To improve morbidity and mortality, most
patients in congestive heart failure should
be treated with an angiotensin-converting
enzyme inhibitor. [Evidence level A, RCT]”
™™ “The USPSTF recommends that clinicians
routinely screen asymptomatic pregnant
women 25 years and younger for chlamydial
infection. [Evidence level B, nonrandomized
clinical trial]”
™™ “The American Diabetes Association
recommends screening for diabetes every
three years in all patients at high risk of the
disease, including all adults 45 years and
older. [Evidence level C, expert opinion]”
 Chapter 37: Evidence-based Medicine: Principles 371

Fig. 37.2  Steps in guideline development

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 372  Section 9: Education and Research
Table 37.2  Some examples of questions that EBM can help to answer are:

Specific question EBM category

• Should we prescribe COX-2 inhibitor or proton-pump inhibitor plus non-selective Treatment question
COX inhibitor for elderly people with painful osteoarthritis?
• What is the chance that fibrates will reduce coronary mortality in women with
isolated low-high density lipoprotein cholesterol?
• Should we screen the general population for colorectal cancer using fecal occult Diagnostic test question
blood test?
• What is the chance that raised prostate—specific antigen correctly diagnoses
prostate cancer in men over 60 years of age without urinary symptoms
• What is the chance that cell phones cause cerebral tumors? Risk factor question
• What is the chance of an infant suffering from HIV after being delivered by Prevalence question
cesarian section of a mother suffering from AIDS?
• What is the chance in a given year a patient with Rheumatic arthritis developing Incidence question
valvular heat disease who is not on prophylactic antibiotic therapy?

Table 37.3  Question and evidence-based study
support
Type of Question/
Domain
Therapy/Treatment
Selection of treatments
or interventions that do
more good than harm
and that are worth the
effort and cost
Diagnosis
Selection and
interpretation of
diagnostic tests, in order
to confirm or exclude
a diagnosis, based
on considering their
precision, accuracy,
acceptability, expense,
safety, etc.
Prognosis
Estimation of a patient’s
likely clinical course over
time and anticipation of
likely complications of
disease
Harm/Etiology Cohort Studies
Identification of causes
or risk factors for disease
Prevention
Quality Improvement
Adapted from: Sackett et al. Evidence-Based Medicine: How to
Practice and Teach EBM
Type of Study/
Methodology
Double-Blind
Randomized Controlled
Trial (RCT), Systematic
Review/Meta Analysis
of RCT
Controlled Trial
Systematic Review/Meta
Analysis of Controlled
Trial
Cohort Studies, Case
Control, Case Series
RCT, Cohort Studies
RCT
3. Critically appraising the evidence
Several Internet sites that appraise the
research literature for readers have been
developed. Physicians can go directly to
these web sites to find the evidence they are
seeking. Several sites offer ‘best evidence’
on a number of specialties for either
primary caregivers or specific specialties.
The following are a few established web
sites (Table 37.4).
Basically, appraisal involves looking first
at most reliable studies and comparing and
contrasting their results. In most situations,
they all find more or less the same kind of result.
The results of these studies can be summarized
either in descriptive form of ‘compare and
contrast’ results or using a technique called
‘meta-analysis’. This process is typically time-
consuming, requiring organizational support,
including statisticians. The use of above websites
provides easy source of readily available and
updated evidence based information.
4. Applying evidence based data to the
clinical problem:
This step requires physicians to apply the
validated evidence to the particular clinical
situation or patient. Both the objective and
subjective data are collected. Some of the
questions that need to be answered in this
process are:

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 Chapter 37: Evidence-based Medicine: Principles 373
Table 37.4  EBM-Websites ™™ Document the strength (i.e. grade or
Web source URL level) of the evidence that supports each
BMJ publishing group http://clinicalevidence. recommendation.
clinical evidence bmj.com/x/index.html ™™ Not only make statements about which of
The Coherence http://www.cochrane. the two options (treatments) is better, but
database org/ quantify the difference in outcome, including
The National Guideline http://www.ahrq.gov/ benefit and harms, between them.
Clearing house clinic
™™ Provides a comprehensive summary of the
American College of http://www.acponline.
Physicians Journal Club org/journals/acpjc/ available evidence, the clinician therefore
jcmenu.htm is freed from the onus of having to search,
Bandolier http://www.jr2.ox.ac.uk/ review and assimilate all such evidence.
bandolier/ ™™ Helps physicians to decrease inappropriate
Centre for Evidence- http://cebm.jr2.ox.ac.uk/ variability in medical practice and to
based Medicine
practice according to emerging research
TRIP Database http://www.ceres. evidence.
uwcm.ac.uk/frameset.
cfm?section=trip ™™ Can also be accessed by patients and
U.S. Preventive http://www.ahrq.gov/ consumers. They can therefore be aids to
Services Task Force clinic/uspstfix.htm interaction between the patient and their
(USPSTF) health care providers. Guidelines provide
PubMed http://www.ncbi.nlm.nih. information to permit joint decision making
gov/pubmed
between parties to pursue outcomes that
they both agree and desirable.
ƒƒ Is the diagnostic test or treatment based
™™ Can be effectively applied to evaluate
on evidence is accurate for the patient’s
various health care services and procedures
specific condition at this particular
in terms of their costs and outcome, the
institution?
results of which can be translated into
ƒƒ Are the diagnostic tests or treatment
cost control and quality improvements in
procedures suitable in terms of
practical health care development.
patient’s capabilities, preferences and
quality of life?
ƒƒ Do the treatment or procedures Limitations of Ebm
used provide answers to the clinical There are theoretical and practical limits to
questions and, if not how the process EBM/guidelines.
can be improved? Theoretically, EBM addresses questions
5. Evaluation of performance such as, “What is the chance/risk” of a certain
Although EBM is now widely accepted drug, procedure, etc. which compare benefit
and used in primary care as well as in or harm to the patient. It does not answer
many specialties, it remains a relatively questions such as “how or why” a drug or a
young discipline. Its positive impacts procedure acts the way it does. This limits
are beginning to be validated, and it will the application of EBM to an important, but
continue to evolve. defined, subset of questions in clinical practice
or policy decisions.21
Advantage of Ebm Practical limitations usually encountered are:
Evidence based guidelines: ™™ Insufficient data/evidence for too many
™™ Clearly differentiate ‘opinion’ from ‘evidence’. problems and poor generalizability

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 374  Section 9: Education and Research
™™ Insufficient skills for interpreting evidence
based information, which can lead
physicians reaching invalid conclusions
in translating evidence into guidelines
™™ Biases or conflicts of interest among
panel members can produce different
recommendations than the data support
™™ Evidence-based guidelines often do not
change practice behavior of physicians. Most
studies indicate that passive dissemination
of guidelines, such as publishing them in a
medical journal, is ineffective in charging
behavior. Guidelines have been shown to
be effective in changing practice patterns
when they are accompanied by active
implementation strategies, such as standing
orders, reminder systems, audit academic
detailing and feedback.22
™™ Practice guidelines can have adverse
implications for clinicians, especially
if they are rigidly enforced by Health
Management Organizations (HMOs),
Mediclaim or malpractice courts. They
can have adverse policy implications for
society if they increase the costs of care,
decrease quality, or divert resources from
more effective health care interventions.
™™ The need to develop new skills in searching
and critical appraisal can be discouraging.
Busy physicians have limited time to
master and apply their new skills and the
resources required for instant access to
evidence—to obtain relevant evidence
to assist in clinical decision-making
at the time of patient’s visit—are often
inadequate in majority of clinical settings.
Misconceptions about EBM
EBM has elicited some confusion and
misconceptions among many physicians.
Sackett and his colleagues have observed the
following common misconceptions raised by
physicians in their work with EBM:17
1. It’s what we have always done.
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Correction: Because of much of medical
practice has been based on traditional
medical education and global subjective
judgment without broad access to
electronic database, this review is clearly
not well founded.
2. It will replace clinical judgment.
Correction: EBM makes clinical autonomy
more thoughtful and more transparent.
EBM increases, rather than diminishes,
professional responsibility and authority,
because it provides a much more secure
basis for decision-making.
3. It will foster ‘cook-book’ medicine.
Correction: Good guidelines are not
‘decisions’ but rather ‘decision aids’. They
articulate summary statements, which
facilitate decision-making. The process of
EBM requires that physicians assess the
quality and relevance of whatever current
evidence can be found. In an individual
clinical situation, the physicians’ need to
apply the evidence as it is appropriate to
the patients needs and preferences, where
in guidelines are helpful.
4. I don’t have time for it.
Correction: With continued advances in
medical informatics and ready availability
of predigested evidence-based analysis of
common clinical problems, this problem
may well decrease in future.
Conclusion
With the growth of clinical research during
the last 30 years, together with new emphasis
on cost and outcome assessment and the
increased use of randomized clinical trails and
meta-analysis, EBM is being hailed as a new
paradigm of medical education and practice.
Rooted in the epidemiology, EBM has the
potential to inform and guide clinical decision
making not only for the care of individual
patient but also for cost effectiveness analysis
and health policy for population being served.
 Chapter 37: Evidence-based Medicine: Principles 375
The application of EBM can thereby help
formulate clinical practice guidelines for
quality performance measures in healthcare
delivery system. At the same time, EBM
requires institutional support by way of
specialist skills, supply of evidence, and widely
accepted standards, which will take some
time to be widely available. In the meantime,
clinicians can benefit from learning evidence
based interpretive skills both for informing
their own practice and for contributing to its
future healthy health care delivery system.
References
1. Kevalas R. Febrile infant and small child: what
solution could be rational?. Medicina (Kaunas),
2005;41(11):974–87 [PMID: 16333221: Free
Article].
2. Guidance for Clinicians on the Use of Rapid
Influenza Diagnostic Tests
We b s i t e : h t t p : / / w w w . c d c . g o v / f l u /
professionals/diagnosis/clinician_guidance_
ridt.htm (Accessed on 19-07-2013).
3. Recommendations for Management of
Common Childhood Conditions: Evidence
for Technical Update of Pocket Book
Recommendations, WHO 2012.
Available from: http://www.ncbi.nlm.nih.gov/
books/NBK138338/
4. Geyman JP. Evidence-based medicine in
primary care: an overview. J Am Board Fam
Pract, 1998;11(1):46–56.
5. Geyman JP. Evidence-based medicine in
primary care: an overview. J Am Board Fam
Pract, 1998;11(1):46–56 [PMID: 9456447].
6. Baraff LJ, et al. Probability of bacterial infections
in febrile infants in less than three minths of age: a
meta-analysis. Paed infect Dis J, 1992; 11:257–64.
7. Baraff LJ, et al. Practice guidelines for the
management of infants and children 0 to 36
months of age with fever without source. Ann
Emerg Med, 1993;22:1198–1210.
8. Oppenheim Pl, et al. Incorporating patient
preferences into practice guidelines.
Management of children with fever without
source. Ann Emerg Med, 1994;24:836–41.
mebooksfree.com
9. Slowther A, et al. Ethics of evidence based
medicine in the primary care setting. J Med
Ethics, 2004;30(2):151–5. [PMID: 15082808:
Free PMC Article].
10. Bradt P, et al. How to teach evidence-based
medicine. Clin Perinatol, 2003;30(2):419–33.
[PMID: 12875363: Abstract].
11. Harrison MB, et al. Adapting clinical practice
guidelines to local context and assessing
barriers to their use. CMAJ, 2010;182(2):E78–
84. doi: 10.1503/cmaj.081232. Epub 2009 Dec
7. [PMID: 19969563: Free PMC Article].
12. Didshury P. Benefits of best practice guidelines.
New Zealand Fam Phys, 2003;30(5):317–23
13. Evidence based medicine working group.
Evidence basec medicine. A new approach to the
practice of medicine. JAMA, 1992;268:2420–5.
14. Cochrance AL. Effectiveness and efficiency.
Random reflections on health services.
London, UK: Nuffield Provincial Hosp. Trust;
1972.
15. Chalfin DB. Evidence Based Med. And cost
effectiveness analysis. Crit.Care Clin, 1998;14:
525–37.
16. Users’ guide to EBM. JAMA, 1992;268(17):
2420–25.
17. Sackett DL, et al. Evidence based medicine:
what it is and what it isn’t. BMJ, 1996;312
(7023):71–72.
18. Mc Kibbon KA. Evidence based practice.
Bulletin of the Medical Library Association,
1998;86(3):396–401.
19. Donald Anna. How to practice EBM. Medscape
General Medicine, 2003;5(1).
20. Appendix A: How the US. Preventive Services
Task Force Grades Its Recommendations
Guide to Clinical Preventive Services, 2012
Web site: http://www.ahrq.gov/professionals/
clinicians-providers/guidelines-
recommendations/guide/appendix-a.html
(Accessed on 20-07-13).
21. Anna Donald. Evidence-Based Medicine: Key
Concepts, Medscape General Medicine, 2002;
4(2).
22. Davis DA, et al. Evidence for the effectiveness
of CME: a review of 50 randomized controlled
trails. JAMA, 1992;268:1111–17.
 38 Evidence-based
medicine: PRactice

“Evidence is not implemented in a simple linear way, as some definitions of evidence-

based practice imply, but in an evolving process whereby reciprocal contributions from
the doctor and the patient over time influence how evidence ultimately is used.”
Freeman AC

Evidence-based Practice Unfortunately, even though providing

evidence-based care is an essential component
Evidence-based practice (EBP) is the
of health care quality, it is well-known that
conscientious and judicious use of current best
evidence-based practices are not used
evidence in conjunction with clinical expertise
consistently, and much of the evidence is not
and patient values and preferences to guide
acted on everyday clinical practice. This is
health care decisions.1 The full integration of
especially the case in general/family practice
these three components into clinical decisions
wherein patient centered factors exert a powerful
enhances the opportunity for optimal clinical
influence on clinical decision-making. The
outcomes and quality of life (Fig. 38.1).
majority of family physicians and primary health
“Evidence-based practice,” “evidence-
care providers have a sceptical view toward EBM
based medicine,” “evidence-based healthcare,”
and their enthusiasm in its implementation has
“evidence-informed practice” and similar terms
been tempered with some doubts.3
all revolve around using the highest quality basic
and clinical research information to make a
Adherence of Ebp in General
well-formed decision to the health care needs
of populations and individuals. This implies
Practice/Family Medicine
that EBP appropriately applies evidence to the Family physicians and primary health care
specific situations and unique needs of patients. providers have a commitment to quality care

Fig. 38.1  The domain of evidence-based practice

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 Chapter 38: Evidence-based Medicine: Practice 377
and attempt to practice on the basis of their
knowledge of the most effective management
strategy for a particular condition. The unique
advantage of their trusted relationship with
patient and families adds to the sustenance in
the management of their problems by taking
into account many facets of the patient’s life.
However, in the last few decades the
amount of information concerning available
treatment and management options for
many conditions has increased exponentially.
Although this development has particular
relevance for general practice given the breath
of conditions managed, there are reasons
for pause before accepting in an uncritical
manner the tenets of EBP as applicable to
primary health care delivery system.
Generally, general practitioners have been
cautions about the evidence-based model.
In one of the questionnaire study of general
practitioners’,4 it was noted that, “the major
perceived barrier to practicing evidence-
based medicine was lack of personal time….
reading all important articles to keep in touch
with relevant information was impossible…
GPs thought the most appropriate way to
move toward evidence-based general practice
was by using evidence-based guidelines or
proposals developed by colleagues”.
In another cross-sectional electronic
survey among 703 GPs in the Netherlands,5
to address the attitudes toward guidelines in
general, and to rate their perceived adherence
and barriers to their implementation, it was
found that only rarely did general practitioners
made use of the research service offered; the
reasons included lack of time and the general
practitioners’ doubts that the service would be
of benefit to their patients.
In an Australian GP study, 6 the most
commonly cited barrier to EBM was ‘patient
demand for treatment despite lack of evidence
for effectiveness’, and the preferred resources for
EBM included clinical practice guidelines and
journals that summarize research evidence.
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Concerns about Ebm in Primary
Care Practice
Although EBM is an invaluable tool for the
practice of medicine because it facilitates a
systematic examination of study methodology
and its clinical application, physicians, however,
predictably face difficulties when they try to
apply EBM in actual clinical practice, and they
may not be able to answer all questions about
patient care using the EBM model.
The evidence obtained from studies such
as those quoted above suggest that the central
assumptions of the EBM/EBP paradigm may
not be shared by many general practitioners,
making its application in general practice
problematic.
Concerns that primary health care providers
have expressed, either about EBM, or its
possible use, may be summarized as below:
Restrictive Definition of ‘Evidence’ as
Applicable to EBM
The definition of ‘evidence’ as applicable
to EBM is highly restrictive; it eliminates a
number of important inputs to the clinical
decision-making process that would be
considered under a broader definition of
evidence. For example, patient values and
preferences, which are meant to be integrated
into decision-making (i.e. patient centered
care), are excluded as forms of evidence. It’s an
acknowledged dictum that clinical medicine
is a discipline that involves individuals and
therefore the art of medicine must take into
account particular individual attributes (i.e.
autonomy) in the context of evidence that is
available.
The evidence derived during the course
of clinical practice—the type of practical,
experiential knowledge that only develops
over time—is also excluded in the initial model
of EBM. Feinstein AR et al state,7 “… the new
collection of “best available” information has
major constraints for the care of individual
 378  Section 9: Education and Research
patients derived almost exclusively from pharmaceutical and medical device industries
randomized trials and meta-analyses, the data … this has occurred because physicians have
do not include many types of treatments or allowed it to happen, and it is time to stop.”11
patients seen in clinical practice.”
Disparity between the “Levels of
Concern about the Credibility of
Evidence”
Evidence
The disparity between the “levels of evidence”
Family physicians have expressed concern
or “strength of recommendation” (Table 38.1)
about the credibility of evidence. A recent
and its importance in terms of therapeutics
study on the promotion of EBM in primary
and preventive application can be a misleading
case showed that while family physicians are
factor in the context of EBM. For example, most
generally accepting the concept of EBM, they
of the diseases seen in family practice have a
have difficulty with the credibility of certain
large lifestyle component; hyperlipidemia,
evidence claims.8 Part of the explanation is the
obesity, smoking, alcohol, hypertension,
explosion in the number of industry-sponsored
combined with sedentary life style are the
randomized clinical trials, especially the
major factors in chronic diseases such
growing influence that large pharmaceutical
as coronary heart disease, stroke, type 2
companies are capable of undermining the
diabetes, osteoporosis, chronic respiratory
truth about the published evidence doctors
diseases, and some specific cancers. These
use to treat patients. The suspicion is that
risks factor can only be effectively modified
pharmaceutical companies may be trading
by health education and disease prevention
lives for profits.9
at the level of the whole population and
Clinical trials are one of the main sources
results reported in population studies. The
of information that guide doctors when they
WHO 2008–2013 Action Plan for the Global
treat patients. However, there are many studies
Strategy for the Prevention and Control of
in the literature claiming that drug promotion
Noncommunicable Diseases states, “these
may lead to ethical problems, irrational use
diseases are preventable. Up to 80% of heart
of medication, and increased costs, as well
disease, stroke, and type 2 diabetes and over
as negative effects on the patient-physician
a third of cancers could be prevented by
relationship and the medical profession. 10
eliminating shared risk factors, mainly tobacco
The many instances of controversial drug
withdrawals have given doctors good reasons Table 38.1  Strength of recommendation: Taxonomy
to be sceptical about the evidence that reaches
Strength of Definition
them, and eroded their trust in the evidence recommendation
base. Some of the reputed journals have drawn A Recommendation based on
attention to the failure of such companies to consistent and good-quality
publish unfavorable trails and thereby basing patient-oriented evidence
the evidence. Further bias arises from the B Recommendation based on
professional journals in which contradictory inconsistent or limited-quality
patient-oriented evidence
conclusions are drawn in various drugs
C Recommendation based on
and procedural trails. The JAMA editor-in-
consensus, usual practice,
chief, Catherine DeAngelis, MD, says, “The opinion, disease-oriented
profession of medicine, in every aspect— evidence, or case series for
clinical, education and research—has been studies of diagnosis, treatment,
prevention, or screening
inundated with profound influence from the

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 Chapter 38: Evidence-based Medicine: Practice 379
use, unhealthy diet, physical inactivity and the
harmful use of alcohol … promotion of health
across the life course and prevention are the
most important components for reducing the
burden of premature mortality and disability
due to such diseases.”12 However, such studies
only reach Grade B evidence even though the
results may have great impact on the public’s
health.
Guidelines could be Misused or
Abused
Narrowly focused clinical practice guidelines
could be misused or abused to implicate
negligence to GPs adopting different
management strategies in complex cases,
which have adverse outcomes.13,14
Clinicians fear that the proliferation
of guidelines will increase their medico
legal exposure. However, notwithstanding
the medicolegal implications of clinical
practice guidelines, Samanta A, et al, while
discussing the Apex court arguments states,”…
Guidelines are not mandatory… they need
to be interpreted and applied in a way that
is clinically appropriate … and therefore
could be overridden by clinical judgment in
an individual case… they represent just one
option for improving the overall quality of
clinical care.”15
Evans JG, in his article titled, “Evidence-
based and evidence-biased medicine” states,
“There is a fear that in the absence of evidence
clearly applicable to the case in hand a
clinician might be forced by guidelines to
make use of evidence which is only doubtfully
relevant, generated perhaps in a different
grouping of patients in another country and
some other time and using a similar but not
identical treatment.”16
In order to facilitate evidence-based
preventive activities in primary care, the
RACGP has published the Guidelines for
preventive activities in general practice (the
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‘red book’) since 1989. The red book is now
widely accepted as the main guide to the
provision of preventive care in Australian
general practice. It provides the evidence base
for which primary healthcare resources can be
used efficiently and effectively while providing
a rational basis to ensure the best use of time
and resources in general practice.17
Lack of EBM Curriculum
In some faculties, EBM is often taught as an
independent topic and is poorly integrated into
the clinical teaching of residents. Most EBM
education occurs in a journal-club format,
focusing on question development, searching,
and critical appraisal. The challenge of discussing
the evidence with patients is rarely addressed.18
Residents also identified a general lack of
education, time constraints, lack of priority, and
staff disapproval as important factors limiting
incorporation of EBM. Curriculum reform may
help overcome these barriers.19
Barriers in General Practice
Freeman AC et al,20 in their qualitative study to
explore the reasons why general practitioners
do not always implement best evidence in
primary care, identified six main themes that
indicated barriers to implementation:
™™ The process of implementing clinical
evidence is affected by the personal and
professional experiences of the doctor;
™™ The patient-doctor relationship: the
relationship that the doctor has with
individual patients also affects the process;
™™ T h e d o c t o r ’s c h o i c e o f w o rd s i n
consultations can sway patients to accept
or reject clinical evidence. Doctors realize
this and can use it to preempt patients’
decisions;
™™ A perceived tension between primary
and secondary care: the doctors thought
the specialists approach evidence-based
practice differently;
 380  Section 9: Education and Research
™™ General practitioners’ feelings about
their patients and the evidence have an
important role in modifying how clinical
evidence is applied; and
™™ Logistical problems: many primary health
care units aren’t adequately staffed or
supported to implement evidence and
arrange systems for disease management.
Essentials of EBM in Primary Care
Practice
Since family/general practice is a broad-based
specialty and an essential foundation in effective
healthcare systems, it follows that providing
evidence-based primary care should reflect
positively on the community’s health. Further,
the practice of family/general practice involve
knowledge of a wide array of different problems;
therefore, it necessarily requires the physician
to manage a broad range of conditions, which
are typically presented in an ill defined manner,
incorporating therein not just physical aspects
of illness, but also mental, social, environmental
circumstances. Hence, to be useful to the
community at large, EBM and clinical practice
guidelines may be formulated with the following
essential features incorporated therein:
™™ Clinical guidelines may be based on
evidence, which is applicable to family/
general practice setting to identify their
use, limitations and benefits. A rigid
protocol would be inappropriate for the
complexities of conditions presenting in
general practice and may therefore not
improve health outcomes.
™™ It is important that clinical guidelines
formulated on the basis of assessed
evidence that are developed by practicing
physicians in such a way as to provide
useful assistance in practical settings rather
than merely as a ‘recipe’ for intervention.
™™ It is crucial that the skills and judgments
of physicians in the practical setting are
respected and enhanced by EBM.
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™™ Increasingly many physicians will practice
in a multidisciplinary context, and where
appropriate, clinical guidelines should
be constructed in a multidisciplinary
environment so that they are able to
promote effective teamwork in relevant
practice settings.
™™ Promoting and improving access to
summaries of evidence, rather than teaching
all general practitioners literature searching
and critical appraisal, would be the more
appropriate method of encouraging
evidence-based general practice.
The Future of EBM in Primary Care
Finally, there is the issue of the new EBM.
In a recent article, Haynes et al21 in BMJ
have stated, “A criticism directed at EBM is
that it ties the hands of practitioners and robs
patients of their personal choice in reaching in
decision about optimal care. There are many
barriers to implementing health research in
practice, but conceptually at least tying clinical
hands and robbing patients of their choices are
not among them. Rather patients’ preferences
were incorporated into the first model of EBM
(Fig. 38.2) and their importance has been
underscored in a recent revision depicted in
the Figure 38.3.”
In the newly devised model of EBM, “clinical
expertise” is placed at the center of overlapping
concerns with three essential components.
Contemporary Definition of EBP22
Since the early definition proved to have some
important limitations in practice, i.e. did not pay
enough attention to the traditional determinants
of clinical decisions by purposefully
emphasizing research knowledge but did not
equally emphasize the individual’s advocacy
in terms of needs, situation, wishes and goals;
and also eliminated the clinician’s expertise
in assessing and integrating all these elements
into a plan of intervention, a contemporary
 Chapter 38: Evidence-based Medicine: Practice 381
Fig. 38.2  A model for evidence-based clinical decision
[Haynes RB et al. APC journal club 1996;125(3):A14-16]
Fig. 38.3  An updated model for evidence-based clinical
decisions
(DaCruz D. You have a choice, dear patient. BMJ
2002;324:674)
definition of EBP is favored which is simply “the
integration of the best research evidence with
clinical expertise and patient values” (Sackett, et
al. 2000). This simpler, current, definition gives
equal emphasis to:
1. Patient preferences and actions: The
patient’s situation, goals, values and
wishes and also patient’s clinical and
physical circumstances to establish what
is wrong and what treatment options
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are available. In any given situation the
patient’s clinical stage and circumstances
may predominate. For example, a patient
with chest pain staying in a remote location
may have to settle for aspirin, if it is the only
effective treatment at hand, whereas one
in an urban set up will likely have more
treatment options. In another situation,
the patient’s preferences make take
precedence. For example, a patient with
myocardial infarction in whom primary
PTCA is indicated may accept only an
alternative conservative therapy.
2. Research Evidence: The best available
research evidence obtained for clinical
application varies from one patient to
another according to individual clinical
circumstances. Patient’s age, sex, existing
risk factors, and other variables need to be
considered. Thus, evidence alone does not
lead to decision-making process. Given the
likely consequences associated with each
option, the physicians must consider the
patient’s preferences and likely actions
(in terms of what interventions he or she
is ready and able to accept).
3. Clinical expertise: The clinical expertise
of the practitioner to bring these
considerations together and recommend
the treatment so that the patient is
agreeable to accepting.
In summary, the patient may refuse
interventions with strong research support due
to differences in beliefs and values. Similarly,
the clinician may be aware of factors in the
situation (co-occurring disorders, lack of
resources and lack of funding) that indicate
interventions with the best research support
may not be practical to offer. The clinician may
also notice that the best research was done
on a population different from the current
client, making its relevance questionable, even
though its accuracy is strong. Such differences
may include age, medical conditions, gender,
race or culture and many others.
 382  Section 9: Education and Research
Conclusion
The term EBM was developed to encourage
family physicians/general practitioners and
patients to pay due respect—no more no less to
current best evidence in making decisions. An
alternative term that may find more appealing
is, “Research enhanced Health care”.23 The
focus of task now is to articulate both a theory
of evidence in clinical practice that admits a
variety of inputs into consideration. The newly
revised model of EBM is a step in that direction;
however, it is clear that primary care providers
and family physicians have much to contribute
to the ongoing evolution of EBM, as they are the
central interface with the healthcare system.22
References
1. Sackett DL, et al. Evidence-based medicine:
how to practice and teach EBM. London:
Churchill-Livingstone; 2000.
2. Sackett DL, et al. Evidence based medicine:
what it is and what it isn’t. BMJ 1996;
312(7023):71–2.
3. Saitz R. Evidence-based medicine: time for
transition and translation (to practice). Evid
Based Med. 2010;15(4):103–4. doi: 10.1136/
ebm1094. Epub 2010 Jun 22. [PMID: 20570949:
Full text].
4. McColl A , et al. General practitioner’s
perceptions of the route to evidence-based
medicine: a questionnaire survey. BMJ, 1998;
316(7128):361–5. [PMID: 9487174: Free PMC
Article].
5. Lugtenberg M, et al. Perceived barriers to
guideline adherence: a survey among general
practitioners. BMC Fam Pract, 2011;12:98. doi:
10.1186/1471-2296-12-98.[PMID: 21939542 :
Free PMC Article].
6. Young JM, et al. Evidence-based medicine
in general practice: beliefs and barriers
among Australian GPs. J Eval Clin Pract, 2001;
7(2):201–10. [PMID: 11489044: Abstract].
7. Feinstein AR, et al. Problems in the “evidence”
of “evidence-based medicine”. Am J Med, 1997;
103(6):529–35.[PMID: 9428837: Abstract].
mebooksfree.com
8. Tracy S, et al. Qualitative study of Canadian
Family Physician’ perceptions of EBM. BMC
family practice, 2003;4:6.
9. Lexchin J, et al. Pharmaceutical industry
sponsorship and research outcome and quality:
systematic review. BMJ, 2003;326(7400):
1167–70. Review. [PMID: 12775614: Free PMC
Article].
10. Civaner M. A proposal for the prevention of
ethical problems related to drug promotion:
a national network for drug information. Turk
Psikiyatri Derg. 2008 Fall, 19(3):310–7. [PMID:
18791884: Free Article].
11. Berger E. Ghostwriters, data manipulation and
dollar diplomacy: how drug companies pull
the strings in clinical research. Ann Emerg
Med, 2008;52(2):137–9. [PMID: 18672488].
Web site: http://www.annemergmed.com/
article/S0196-0644%2808%2900941-4/
fulltext#sec1(Accessed on 22-07-13).
12. World Health Assembly Document A61/8 (18
April 2008)
We b s i t e : h t t p : / / w w w . w h o. i n t / n m h /
publications/ncd_action_plan_en.pdf
(Accessed on 22-07-2013).
13. Lohr KN. Guidelines for clinical practice:
applications for primary care. Int J Qual
Health Care, 1994;6(1):17–25. [PMID: 7953199:
Abstract].
14. Bogdan-Lovis E, et al. It’s NOT FAIR! Or is it?
The promise and the tyranny of evidence-
based performance assessment. Theor Med
Bioeth, 2012;33(4):293–311. doi: 10.1007/
s11017-012-9228-y.[PMID:22825592: Abstract].
15. Samanta A, et al. Legal considerations of clinical
guidelines: will NICE make a difference? J R Soc
Med, 2003;96(3):133–8. [PMID: 12612117: Free
PMC Article].
16. Evans JG. Evidence-based and evidence-biased
medicine. Age Ageing, 1995;24(6):461–3.
[PMID: 8588532: Full final text].
17. Harris MF, et al. Developing the guidelines for
preventive care - two decades of experience.
Aust Fam Physician, 2010;39(1-2):63–5. [PMID:
20369139: Free Article].
18. Korenstein D, et al. Mixing it up: integrating
evidence-based medicine and patient care.
 Chapter 38: Evidence-based Medicine: Practice 383
Acad Med, 2002;77(7):741–2. [PMID: 12114160:
Abstract].
19. Bhandari M, et al. Challenges to the practice
of evidence-based medicine during residents’
surgical training: a qualitative study using
grounded theory. Acad Med, 2003; 78(11):1183–
90. [PMID: 1460488: Abstract].
20. Freeman AF, et al. Why general practitioners
do not implement evidence: qualitative study.
BMJ, 2001;323(7321):1100–2. [PMID: 11701576:
Free PMC Article].
mebooksfree.com
21. Haynes RB, et al. Physicians’ and patients’
choice in evidence based practice. BMJ, 2002,
2002;324(7350):1350, [PMID: 12052789: Free
PMC Article].
22. Drisko JW. Smith College School for Social
Work Research, Northampton, MA. Web site:
http://sophia.smith.edu/~jdrisko/evidence_
based_practice.htm (Accessed on 24-07-2013).
23. Upshur REG et al. Evidence based medicine in
primary care. New Zealand Fam Phys: 327:330.
 39
“Medical science has developed so amazingly within the past few years that it is now almost
impossible for a doctor to find anything all right about a patient.”
Introduction
Research can be viewed as “Organized
curiosity”, 1 an endeavor to discover facts
or investigation into how and what we do,
whether it works, whether we can do it better
and more effectively.
All medical progress involves learning
about what is already known, which education
is, and learning to find out what is not yet
known, or perhaps has been forgotten,
which is research. Research extends our
quest for knowledge along uncharted ways,
and increases the range and depth of our
understanding.
Background of Research in Family
Medicine
Research has always been part of general
or family practice, particularly in the
area of microbes and their role in disease
causation—the well-known “germ theory of
disease”—in the 19th and early 20th century.
During this period, some of the finest and
epidemiological research was undertaken by
general practitioners, such as, Louis Pasteur
(1822–1895), Robert Koch (1843–1910),
Edward Jenner (1749–1823), Ronald Ross
(1898), Patrick Manson (1900), many such
ingenious physicians.
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Research in
Family Medicine
Earl Wilson.
With the development laboratory methods
for early detection of disease at the close of
19th century, medicine moved faster toward
specialization. Further, “with the advent
of biomedical techniques and increasing
sophistication of basic sciences, research
methodology moved into hospitals and
laboratory settings. The belief subsequently
developed that research was the province of
only certain kinds of scientists”.2 For example,
Sir James Mackenzie noted:
“About 1883, I resolved to do a series of careful
observation, entirely for my own improvement,
never dreaming of research, for I was under the
prevalent belief that medical research could
only be undertaken in a laboratory or in a
hospital.2,3
This belief is still prevalent among the
majority of primary care providers. Currently,
family medicine research into common clinical
problems is relatively limited mainly because
they occur outside hospitals and are unexciting
to highly trained research professionals. The
family medicine research activity that does
exist on common clinical topics in family
practice—the common cold, hypertension,
rashes, and many others—is mostly descriptive
in nature; i.e. the research has studied how
physician and patients deal with the problem,
rather then having determined the best way to
 Chapter 39: Research in Family Medicine 385
deal with the problems of the patient viewed in
the context of the family. 4 Ronald Goldschmidt
et al, in their article “the family in the family
medicine literature” conclude that, “unique
family medicine approaches and perspectives
are not discussed commonly in clinical article
in the family medicine literature”.5 Further,
in one of the study by Mainous et al6 found
that most family medicine department chairs
placed a relatively low priority on research;
most chairs ranked research as fourth on a list
of five priorities—below clinical activates and
below most educational activities.
One may then ask why this neglect has
occurred. The answer may lie in Dawber’s
comments:
“The tremendous growth of medical research
has created an echelon of professional
researchers concentrated in academic
institutions—it has little effect on the solutions
of many of the problems in medical practice—
there is almost no opportunity for physicians
in private practice to participate in the
decision making process (of what should be
researchable questions). Practicing physicians
should have a much louder voice in suggesting
the direction in which research should go.2,7
This paucity of research in family medicine
has left has us in a situation whereby most of
what we know about how to diagnose and treat
common clinical problems is derived from the
expert opinion of specialists and from research
generated in tertiary care research settings.
As numerous authors have noted, such
information may or may not be applicable to
primary care practice in general or to family
practice in particular.
For example, diagnostic tests have a
different significance depending on the patient
population in which the tests are obtained.
Routine diagnostic methods such as CT
scan and MRI in an exclusive neurological
practice for evaluation of headache is likely
to turn up occasional brain tumors an other
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intra cranial lesions; while frequent use of
such neuro-imaging on unselected patients
in family practice office will generally waste a
lot of money. Similarly, a positive antinuclear
antibody test in a patient with joint pain is
likely to signify the presence of disease in
a rheumatologist’s office, while the same
positive test in the “unselected” patient
population of a family practice office is most
likely a false positive result.4
What Constitutes Family/General
Practice Research?
Research conducted by family physicians and
general practitioners themselves within their
own practice settings clearly, can be labelled
family/general practice research.
In 1991, Culpepper 8 defined family
medicine research as follows, pointing out
that this definition also could serve for primary
care research:
“Family medicine research addresses the
need for knowledge by family physicians so
they may better manage their patients, their
families, and their practices and fulfill their
health care role at the community level. Further,
family medicine research particularly seeks
to answer questions which require the family
practice setting or the relationship among family
physician, patient, family, and community. It
investigates issues from the family physician’s
and the patient’s perspectives.”
Culpepper argued that while there was still
need for basic descriptive and exploratory work,
including natural history studies in primary care
settings, the discipline must become theory
based, with investigations grounded in the
Institute of Medicine’s definition of primary care:
“the provision of integrated, accessible, health
care services by clinicians that are accountable
for addressing a large majority of personal health-
care needs, developing a sustained partnership
with patients, and practicing within the context
of family and community.”9
 386  Section 9: Education and Research
However, any study could be considered when a combination of both qualitative and
family/general practice relevant research if quantitative forms of inquiry are used.
its findings potentially affect a family practice, Table 39.1 summarizes the difference
whether it is conducted by specialist medical between the qualitative and quantitative
discipline, primary health care colleagues approaches to research.10 In reality, there is
(such as practice nurses and pharmacists) a great deal of overlap between them, the
or other professional groups. For example, a importance of which is increasingly being
sociologist might survey community attitudes recognized
with regards to specific health issues, such
as community response to directly observed Quantitative Research
therapy for tuberculosis; or a pharmacist It includes following types:11
research in how many patients actually
present prescriptions to their chemist; or Cross-sectional Study
a practice nurse reporting her feed back
on family doctor’s follow up therapy. Thus It is based on a single examination of a cross-
family/general practice research should utilize section of population at one point in time, the
and adapt methods from many sources and results of which can be projected on the whole
customize new task-specific tools to enhance population, provided the sampling has been
research in their specialty. done correctly. Cross-sectional study is also
The common denominator is endeavoring to known as ‘prevalence study’—i.e. a study which
provide the best possible health care for patients, tells us about the distribution of a disease in a
and continuing to monitor that physicians’ population rather than its aetiology.
performance is as optimally safe and effective
as current state of knowledge will allow. Table 39.1  Qualitative verses quantitative research
Qualitative Quantitative
Types of Research Methodology Social theory Action Structure
Research “methodology” is the philosophy Methods Observation, Experiment,
or the general principles, which guide the Interview Survey (rigid
(relatively structure of
research, its overall approach to studying unstructured) research
a topic and includes issues such as the design, data
constraints, dilemmas, statistics, and ethical collection and
choices involved in the research. Research analysis)

“methodology” is different from research Question What is X? How many XS?

(Classification) (enumeration)
“methods”—the latter are the tools used to
gather data, such as interviews, questionnaires, Reasoning Inductive* Deductive**

and other appropriate communication Sampling Theoretical or Statistical-

method imaginative huge random
modalities. sampling samples with
Research methodology is generally divided control
into two broad groups: Quantitative and Strength Validity Reliability
Qualitative research. Quantitative research (Closeness to (Repeatability)
generates statistics through the use of truth)
large-scale survey search, whereas qualitative *Inductive = the investigator observes, conceptualizes and them
forms a hypothesis.
research explores attitudes, behavior, and **Deductive = A precise hypothesis is made and the investigator
experience. The term “triangulation” is used sets to collect data to either prove or disprove it.

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 Chapter 39: Research in Family Medicine 387
Case Control Study
They are basically comparison studies; cases
and controls must be comparable with respect
to known “ confounding factors ”, such as age,
sex, occupation, social status, etc. Case control
studies have their major use in the chronic
disease problems when the causal pathway
may span many decades, e.g. malignancies,
CHF, cirrhosis of the liver, etc.
Cohort Study
In epidermiology, the term “cohort” is
defined as a group of people who share
a common characteristic or experience
within a defined time period. Cohort study
is usually undertaken to obtain additional
evidence to refute or support the existence
of an association between suspected cause
and disease. Three types of Cohort studies
have been distinguished on the basis of the
time of occurrence of disease in relation to
time at which the investigation is initiated
and continued: prospective (or current),
retrospective (or historical) and combination
of the two. Some well-known examples of
cohort studies are—the Framingham Heart
study, wherein the relationship of risk factors,
like smoking, serum cholesterol, blood
pressure, weight, etc. to the subsequent
development of cardiovascular disease was
evaluated. Similarly, the Diabetes Control
and Complication Trial (DCCT), wherein
the role of ‘intensive insulin’ as against
‘conventional insulin’ therapy was evaluated
in normalization of blood glucose in type 1
diabetic patient.
Randomized Controlled Trials (RCTs)
This is an experimental epidemiological
study similar to cohort study excepting that
the conditions in which study is carried out is
under the direct control of the investigation.
RCT studies assess the effects of a particular
variable—such as a drug or treatment in which
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subjects are assigned on a random basis to
either of two groups, experimental or control.
The experimental group receives the drug or
procedure while the control group does not.
Laboratory tests or clinical evaluations are
performed on both groups (usually using the
double blind technique) to determine the
effects of the drug or procedure.
RCTs have become of major area of clinical
trials to evaluate various disease processes
and drug therapies in their different forms of
permutation and combination. An example
could be the United Kingdom prospective
diabetes study (UKPDS) designed to establish
in type 2 diabetic patients, whether the risk of
macrovascular or microvascular complication
could be reduced by intensive blood glucose
control with oral hypoglycernic agents or
insulin and whether any particular therapy
was of advantage.
Qualitative Research
Qualitative research aim to “study things in
their normal setting, attempting to make sense
of, or interpret, and phenomena in terms of
the meanings people bring to them”, and they
use “a holistic perspective which preserves the
complexities of human behavior.”11
In family practice a number of authors
have conducted qualitative research in
areas such as doctor-patient relationship,
practice organization, medical education at
undergraduate and postgraduate levels, research
training methodology in family medicine,
and many such subjects. With research in
practice organization, medical records have
been standardized, precise and comparable
internationally. Subject of practice organization
also includes designing clinic, efficient time
management by doctor, uses of computers in
maintaining patient records, effective use of
paramedical staff and group practice. All these
have improved a great deal in last 20–25 years as
a result of qualitative research in family practice.
 388  Section 9: Education and Research
Following are some of the methods employed
in qualitative research:11
™™ Direct or passive observation—systematic
observation of behavior and talk in
natural occurring situation and often uses
technology such as video cameras.
™™ Participant Observation—In addition to
the above, the researcher becomes much
more involved in the lives of the people
being observed.
™™ In depth interviews—also called as
“unstructured or life history interviews”.
Here the researcher attempts to archive a
holistic understanding of the interviewees’
point of view or situation. There are
no preset questions—the participant is
free to talk about what he/she deems
important, with little directional influence
from the researcher. Further, researchers
have to be able to establish “rapport”
with the participant - they have to be
trusted if someone is to reveal intimate life
information and requires tact, diplomacy
and perseverance.
™™ Focus groups—also called “discussion
group or group interviews”. Here a number
of people are asked to come together in a
group to discuss a certain issue to generate
data. Focus groups may be video recorded
or tape-recorded.
™™ Questionnaires—three basic types of
questionnaire—closed-ended, open-
ended or a combination of both are also
employed to generate data on specific
topics.
Limitations of Quantitative-
Qualitative Research
Most medical research evidence is biomedical
data derived from quantitative research
(especially RCTs) done in secondary and tertiary
care settings. Practicing physicians, especially
family physicians, who have to deal with patients
with “undifferentiated problems” living in “real-
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world” consisting of “unselected population”,
often find it hard to follow such evidence. Some
of the limitations of application of evidence of
RCTs in family practice are:
™™ Family practice has a different population
and deals with different conditions in
comparison to hospital-based practice.
Practices vary widely in nature according to
location, ethnic, and socio-economic factors.
™™ Patients in family practice often have complex
multifaceted problems with both biological
and psychosocial components. General
practitioners often have to manage multiple
interacting factors. Occasionally patients do
present with simple symptoms that require
a simple diagnosis and cure, but more often
they have a multiple interwoven issues that
need unraveling. Therefore, may not be
possible to eliminate biases and confounders
in research methodology, especially in RCTs.
™™ In areas of medicine where psychosocial
dimension is a major component,
quantitative research becomes a blunt and
cumbersome tool. In some situations, only
qualitative methods can yield meaningful
results, e.g. the emotions of terminally ill
patients and the doctor-patient relationship.14
™™ In family practice a well-taken history by
a physician is a testimony of the patient’s
experiences, not only of the current illness
for which help was being sought but of his
life, work, family situation and previous
health. In addition to these facts, which
the physician is trying to elicit, the patient
also offers valuable clues to his attitudes,
knowledge, and beliefs about his social,
spiritual, economical and physical aspects
of health. Because qualitative research
tries to understand and interpret personal
experience to explain such aspects of
health, it can address such questions
that quantitative research cannot. Some
examples are: why patients do not comply
with a treatment regimen or why a certain
health care intervention is successful.
 Chapter 39: Research in Family Medicine 389
™™ In general, if the objective of the research
was to explore, interpret, or obtain “deeper
understanding” of a particular clinical
issue, qualitative methods were almost
certainly the most appropriate to use. If,
however, the research aimed to achieve
some other goal (such as determining the
incidence of a disease or the frequency of
an adverse drug reaction, testing cause
and effect hypothesis, or showing that one
drug has a better risk benefit ration than
another), a case-control study, cohort
study, or randomized trial may have been
better suited to the research question.11
™™ Further, best research project might
incorporate a combination of qualitative
and quantitative methods and perspectives
when evaluating a problem. There is an
increasing move toward a multimethod
approach involving the collect, analysis, and
integration of both these types of data.12
Good Research in Family Practice12
For research to be successful in family practice,
several issues should be addressed:
Consultation with Primary
Care Groups
It is essential to consult primary care groups
before the research starts so as to make certain
that the research topic or question is relevant
to everyday practice.
Good Research should Take Account
of the Participants
In medical research, including primary care
research, usually the patients are the subjects
of research; therefore, their needs have to
be considered in terms of benefits, adverse
events, and cost effectiveness.
Be Aware of Competing Interests
The objective of findings what is good for
patients can be compromised by groups
interested in the research for other reasons—
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including pharmaceutical companies. 13
In order to avoid biased outcome result of
research, it is essential to strictly adhere to the
research protocols. A clear understanding of
the objectives and main applications of results
should be declared at the outset.
Consider All Potential Settings
Since family medicine is a broad based
specialty, it is essential that the family
physician is aware of its research potentials
in combination with other closely related
medical specialties. This will unable an
understanding of the relevance of the results
to the diverse range of family practices.
Cultural Issues
In recognition of the changing demography of
primary care practice, consideration of other
ethnic groups is important for good research.
Cultural influences on health and disparities
in outcomes are well documented. This is
of considerable importance in primary care
practice where the whole population has access.
Adequate Resources
Resources, besides financial back up, also
include participation of staff and patients.
Their goodwill should not be taken for
granted. While it is encouraging to be working
toward the greater good, practicalities have
to be taken into consideration in planning
the range and depth of research and its cost
effectiveness. Besides, reimbursement for time
and resources provided by participants need
to be considered.
Ethical Considerations
Ethical considerations may have to be
expanded upon and addressed suitably with
ethics committee.
Team Approach
Conducting rigorous academic research
of high caliber generally requires a team
 390  Section 9: Education and Research
approach. This is best achieved within the
university environment in collaboration
with participating family physicians, general
practitioners, primary health care and social
organizations, statisticians, network and other
key professionals.
Research Strategies for Family
Medicine2
To develop strategies and effective organization
to undertake research in family medicine,
certain prerequisites are needed.
1. Research may be qualitative or quantitative
It may include biomedical, management,
or behavioral fields. Original creative
or coincidental thought and inductive
reasoning are all acceptable and are to be
encouraged.
2. Research activity in family medicine
consists of two major components:
a. Clinical investigation and observation,
hypothesis testing, and critical thinking.
b. Training in data collection, investigative
methods, data analysis, and writing
skills.
3. The research laboratory for family practice
of located in three main areas:
a. University medical school settings
where resources, teaching, and
interdisciplinary activity are possible
and desirable.
b. Hospital in-patient services at university
and community hospital sites
c. Ambulatory “practices” involving
healthy and unwell people in their
homes, communicate, and work places.
Aims and Objectives of Research
in Family Medicine2
It is obvious that the chief purpose of
conducting family medicine research is
to answer research questions relevant to
everyday practice. Good questions are those
that are interesting and important enough
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to be worth answering, and acceptable of
being answered within a predictable and
acceptable time frame. A question is not worth
pursing if the solution is beyond the resource
of the researcher, or will not contribute to
improvements in patient care.
Other significant aims of research in family
medicine should include:
1. To develop research in fields that have been
relatively ignored, such as, early diagnosis,
illness and its effect on health behavior,
psychological factors in health care, the
family as a unit of care placebo effect.
2. To improve the research training of
physicians entering primary care.
3. To develop relationship between family
medicine and other disciplines in the
research area.
4. To substantiate the existence of an
academic component of family medicine
that will be acceptable and equal to that of
other disciplines.
5. Medical students—provide an awareness
of the scope of problems; skills required
to investigate in primary care; encourage
curiosity and self-criticism.
6. Individual physicians—to develop the
capacity to think precisely and logically
about a problem—the physician will
become less open to the fallacies that exist
in medical literature.
7. To substantiate the existence of an
academic component of family medicine
that will be acceptable and equal to that of
other disciplines.
8. To improve healths care for the individual
and the family.
Methodology or Logistics of
Research14 (Fig. 39.1)
1. Define clearly and precisely the aim of
the study. This is the statement of why
the research was done and what specific
question it addressed.
 Chapter 39: Research in Family Medicine 391
Fig. 39.1  Logistics of research
2. Scan the relevant literature.
3. Establish the research team and other key
participants. Meet all the participants of
the research project, discuss and form core
ideas about the chosen topic.
4. Consult a statistician to determine the
sample size to avoid bias and to decide
what level of evidence/significance one
wants from the study.
5. Take help of specialists whenever necessary.
6. Finalize the proforma.
7. Prepare the research protocol.
Protocol is the blueprint for a research
project. It involves thinking, planning and
documentation. Protocol consists of following
sections:
ƒƒ Background and general aims: why is
the study worth doing?
ƒƒ Specific objectives: what exactly do we
want to learn from the trial?
ƒƒ Study population: who precisely will
we study?
ƒƒ Treatment: what exactly will we do to
the subjects?
ƒƒ Trial Design: how will the trial be
organized?
ƒƒ Procedures: how will the trial be
administrated?
ƒƒ Statistical analysis: how will the results
be analyzed and conclusions drawn?
*Ref.–Appendix – 3-WONCA
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ƒƒ Facilities and budget: how will we pay
for it all?
ƒƒ Is it ethical?
8. Preliminary test runs—Sometimes, before
a protocol is completed, preliminary (pilot)
studies have to be made to find out the
feasibility, operational efficiency of certain
procedures, policies, or unknown effects.
9. Project launch and mid-course correct­ions—
The final version of the protocol should be
agreed upon by all concerned before the
trial begins. However, there may be a need
for midcourse corrections before completing
the project (i.e. iterative approach).
10. After the project is over call for proforma.
11. Analyze the data and form a conclusion.
12. Verify it with the hypothesis.
What Can Family Physicians Do
There are many ways in which the family
physicians can actively participate in research.
1. Family physicians can identify the gaps in
their knowledge and generate a research
question needing answers.
2. Family physicians must cultivate the habit
of reading and following research based
articles published in family medicine
and other related journals, which publish
articles of importance in primary care
practice. Such journals are published by
General Practitioners’/Family Physicians’
organizations in countries like USA, UK,
Ireland, Canada, Australia, New Zealand,
Singapore, Hong Kong, to name just a few.
Regular perusal of these journals will help
to identify research-based articles that
may provide insights into the best way to
treat patients in clinical family practice.
An exclusive global Family Physicians’
Organization, “World Organization of
Family Doctors, WONCA”, provides a
wealth of updated articles from reputed
journals published all over the world.*
 392  Section 9: Education and Research
3. While RCTs are generally the best methods
to answer questions on treatment
effectiveness, other methods can be used
to answer different question types. Family
physicians can use qualitative research to
explore a topic and help in formation of a
quantitative research design to explain the
quantitative results, or converge both data
analysis (triangulation), which broadens
the perspective of outcome results.
4. The involvement of family physician in
research may range from study participant
to active collaborator, or even primary
investigator. The latter is more feasible for
the physician engaged in postgraduate
studies with academic support and
guidance.
5. It should be the endeavor of all family
physicians to utilize primary care research
based evidence in their practices instead
of blindly accepting specialty-based
recommendations as the standard of
care for primary care practices. This does
not mean that our specialty colleagues
haven’t a great deal to offer and that we
should not learn from them or seek their
advice. Nor does it mean that they are
not critical participants in healthcare
system who enhance the well-being of
our patients. However, specialty practices
often operate under different logistical
circumstances and involve selected patient
population, which are different form what
family physicians encounter in frontline
primary care practices. Family physicians
need more research guidelines based in
primary care settings, which involve family
practice perspectives in the literature to
a greater degree. “Some modest changes
might generate such a shift. Editors could
encourage authors to address family
*Website: http://www.crncc.nihr.ac.uk/Resources/NIHR%20CRN%20CC/Networks/PCRN/Documents/
nihr_pcrn%20_updated%20March%202012_WEB.2.pdf (Accessed on 29-07-2013).
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practice perspectives when relevant, both
in the instructions to authors and through
the review process”5
6. Participation in “Primary Care Research
Networks”(PCRN)*
With the development of academic faculty
of primary care through out the world,
more primary care practitioners are
participating in research. In order to
develop collaboration between primary
care professionals (general practitioners,
nurses, health visitors, etc.) and a variety
of academic faculties, PCRNs were
established in 1997 in United Kingdom,
although its activity began in the 1960. The
research activity of the PCRNS includes:
ƒƒ Collection of morbidity data
ƒƒ Clinical research
ƒƒ Practice—centered research
ƒƒ Large multicenter trials, and
ƒƒ Research training.
The family physician who is interested in
becoming part of such a research networks
needs to enroll as its member.
Physicians in the networks typically
develop clinical questions and the
network researchers design studies to
answer those questions. The practicing
physicians collect data, which are then
analyzed. Research conducted by PCRNs is
potentially valuable because the research
setting is primary care practices. Shared
planning and discussions can result in
cross-pollination of ideas and skills.
New theories are emerging that may show
haw different professional groups in a
primary care group can words together
more efficiently.
7. In the United States several small and large
networks have emerged since 1980, e.g. the
Ambulatory Sentinel Practice Network.15
 Chapter 39: Research in Family Medicine 393
The ASPN is a network of primary health
care practices across the United States and
Canada offering:
ƒƒ A l a b o r a t o r y f o r t h e s t u d y o f
populations under the care of primary
care providers
ƒƒ Surveillance of primary care problems
and services.
8. Further examples of different styles of
general practice networks are available on
the BMJ website.16 Over 30 networks are
currently members. The research activity
of the networks has included collection
of morbidity data, clinical research,
practice based research, large multicenter
trials, and research training. In future,
research networks may be able to produce
multidisciplinary coalitions of researchers,
provide widespread ownership of research
activity, and motivate members to
disseminate research findings quickly.
Suggested Research Training and
its Incentives Rewards2
Training activates may occur in the following
ways:
1. Medical student—research internship
programs in department of family medicine,
community medicine, and epidermiology.
Rewards—Financial support, presentation
at meetings, publications.
2. Residents—courses in epidermiology and
primary care research methods.
Involvement in individual or group projects.
Rewards—presentations at meetings,
publications, acquisition of special skills.
3. Fellows in Family Medicine—1 or 2 year
postgraduate programs containing a major
component of research training.
Rewards—acquisition of special skills,
publications, presentation at meetings,
improved job opportunities in academic
medicine.
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4. Faculty—in-service training and faculty
development skills.
Rewards—acquisition of research skills,
improved teaching capability, presentation
at meetings, publications, possibility of
grant awards and promotion.
5. Private Practitioners—short-continuing
education courses in research methods.
ƒƒ Part time continuous training programs
ƒƒ Collaborations of project with academic
faculty.
ƒƒ Reward—presentations at meetings,
publications.
ƒƒ Provide stimulus to the practitioner
for postgraduate studies while actively
in practice.
Conclusion
While there are distinguished scientists of
research among family physicians, the research
enterprise has yet to be institutionalized world
wide into the care of family medicine.
Good research for family medicine, of all
types and origins, gives useful results that are
relevant and important for improving practices
and improving health of our patients.
Good research in family practice can
be very rewarding to be a part of, while
respecting the interests of related specialties
and organization involved.
More primary care professionals need to
get involved in research. They need the skills
to access the vast research knowledge, assess
the quality of evidence, and ultimately make
a judgment of the relevance of this knowledge
for an individual patient.
Family physicians, who have training in
critical appraisal of research, are best able to
assess the validity of therapies and procedures
efficiently.
Ultimately, the usefulness of any type of
the research in medicine depends on making
it relevant to the real world of patients and
healthcare providers.
 394  Section 9: Education and Research
References
1. Eimera TA. Organised curiosity. J R Coll Gen
Pract, 1960;3:246–52.
2. Curtis P. What kind of research in Family
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32(6):389–92.
3. Mac Kenzie J. Symptoms and their inter­
pretation, 4th edn. London: Shaw & Sons, 1921.
4. Weiss BD. Why Family Practice Research? Arch
Fam Med, 2000;9:1105–07.
5. Goldschmidt Ronald, et al. The family in Family
medicine Literature. Fam Med, 2003;35(9):
661–65).
6. Mainous AG, et al. A comparison of family
medicine research in research intense and less
intense institutions. Arch Fam med, 2000;9:
1100–04.
7. Dawber RT. Annual Discourse – unproved
hypothesis. New Eng J Med, 1978;299:452–58.
8. Culpepper L. Family Medicine research: major
needs. Fam Med, 1991;23(1):10–4. [PMID:
2001773: Pubmed].
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9. Donaldson M, et al. Primary Care: America’s
Health in a New Era. Washington, DC: Institute
of Medicine, National Academies Press; 1996.
10. Trisha Greenhalgh, et al. Papers that go beyond
numbers (qualitative research): how to read a
paper. BMJ, 7110;315, 1997.
11. Park K. Park’s TB of P& SM, 16th edn: 59–72.
12. Kerse N, et al. What constitutes good research
in general practice? NZFP. 2003;30(6):385–7.
13. Wazana A. Physicians and the pharmaceutical
industry: is a gift just a gift? JAMA, 2000;283:
273–80.
14. Cresswell J, et al. handbook of mixed methods
in behavior and social sciences. Thousand
Oaks, California: Saga publications; 2003.
15. Green LA, et al. The Ambulatory Sentinel
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[PMID: 6699565: Abstract].
16. Thomas P, et al. Networks for research in primary
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11238155: Free PMC Article].
 Appendices

Appendix 1
Indian Medical Association
College of General Practitioners

POSTGRADUATE QUALIFICATION
Started in the year 1963 by Dr PG Batla, CGP was airing at providing knowledge to the general practitioners.
admissions open for all existing and new courses:
1. PGDEM
2. DCH/IPPC
3. MRCGP
4. Fellowship in Family Medicine
5. Diploma in Family Medicine
6. Cardiology
7. Echocardiography
8. Reproductive Medicine
9. Diabetes and Noncommunicable Disease
10. Sexual Medicine
11. Emergency Medicine
12. Cancer Palliative Medicine
13. Sports Medicine and Rehabilitation
14. Ultrasonography
For details of the “contact program courses”—please visit the web site.1,2
For details of the “online courses” offered—please visit the web site.3,4

References
1. http://www.imacgpindia.com/index.php?option=com_content&view=article&id=80&Itemid=455
(accessed on 02-04-2015).
2. Web site - http://www.imacgpindia.com/ (accessed on 02-04-20150).
3. http://www.imacgpindia.com/index.php?option=com_content&view=article&layout=edit&id=151
(accessed on 03-04-2015).
4. http://www.imacgpindia.com/index.php?option=com_content&view=article&layout=edit&id=134
(accessed on 03-04-2015).

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 396  Family Medicine: A Clinical and Applied Orientation
Appendix 2
REVIVAL OF FAMILY MEDICINE: A PRIMARY HEALTHCARE
SPECIALTY

• In 1963, Indian Medical Association started a College of General Practitioners on the lines of Royal
College of General Practitioners of England and Canada.
• In 1966, formal training for family physicians was enacted by law in USA. Similar provisions in Canada,
Australia and other European countries soon followed it.
• In 1977, FCGP (Fellowship of College of General Practice) examination was started by Indian Medical
Association’s College of General Practitioners.
• In 1977 MNAMS (Membership of National Academy of Medicine) examination in general practice
was started, it was later changed in 1982 to DNB (Diplomate of National Board) in Family Medicine.

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 Appendices 397

Appendix 3
WONCA
What’s in a name?
“Wonca” Explained
WONCA is an unusual, yet convenient acronym comprising the first five initials of the World Organization
of National Colleges, Academies, and Academic Associations of General Practitioners/Family Physicians.
WONCA’s short name is World Organization of Family Doctors.
WONCA has come a long way since 1972. WONCA now has 118 Member Organizations representing
over 400,000 family doctors in over 130 countries and territories around the world.

What is WONCA’s Mission?

The mission of WONCA is to improve the quality of life of the peoples of the world through defining and
promoting its values, including respect for universal human rights and including gender equity, and by
fostering high standards of care in general practice/family medicine by:
• Promoting personal, comprehensive and continuing care for the individual and the family in the
context of the community and society;
• Promoting equity through the equitable treatment, inclusion and meaningful advancement of all groups
of people, particularly women and girls, in the context of all health care and other societal initiatives;
• Encouraging and supporting the development of academic organizations of general practitioners/
family physicians;
• Providing a forum for exchange of knowledge and information between member organizations and
between general practitioners/family physicians; and
• Representing the policies and the educational, research and service provision activities of general
practitioners/family physicians to other world organizations and forums concerned with health and
medical care.

WONCA Membership for Individual Doctors

Individual family doctors can join WONCA for a modest fee. WONCA direct member can enjoy reduced
registration fees at all WONCA conferences.
Family doctors around the world are welcome to join the WONCA online discussion area called the
WONCA forum. This provides access to a general discussion area and the new section to ‘Ask a Colleague’
a question. You do not have to be a WONCA member to participate so why not join today.
Note: For more resources for GPs/FPs, please visit the web site: http://www.globalfamilydoctor.com/
Resources.aspx1,2

References
1. Web site : http://www.globalfamilydoctor.com/AboutWonca/brief.aspx (accessed on 02-04-2015).
2. Web site : http://www.globalfamilydoctor.com/member.aspx (accessed on 02-04-2015).

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 398  Family Medicine: A Clinical and Applied Orientation
Appendix 4
Primary Health Care in India*

As per the Alma-Ata conference declaration

“Primary health care is the essential health care made universally accessible to individuals and acceptable
to them, through their full participation and at the cost of the community and country can afford.”
In the Indian context, primary health care is provided by the complex of primary health centers (PHCs)
and their subcenters through the agency of multipurpose health workers, village health guides and trained
dais under the guidance for primary care physicians.
Elements of primary health care in India as defined by the alma-ata declaration are:
• Education concerning prevailing health problems and the method of preventing and controlling them.
• Promotion of food supply of safe water and proper nutrition.
• An adequate supply of safe water and basic nutrition.
• Maternal and child health care, including family planning.
• Immunization against major infectious diseases.
• Prevention and control of locally endemic diseases.
• Appropriate treatment of common diseases and infections.
• Provisions of essential drugs.

*Park k. Park’s textbook of p&sm. 16th. ed:632-633.

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 Appendices 399

Appendix 5A
‘ESSENTIAL’ AND ‘DESIRABLE’ CHARACTERISTICS OF A
BALINT GROUP
(Approved by the Council of the British Balint Society, March
1994)

ESSENTIAL CHARACTERISTICS
1. A small group
There are no absolute rules but groups with less than about six or more than about twelve participants
are unlikely to work well.

2. Defined group leader who is one of the following

GP who has attended Balint type groups and has had some training in small group leadership, ideally to
include co-leading with an experienced Balint leader and/or attendance at the Balint Society leaders’
workshop.
Psychologist, psychoanalyst, counselor or related professional who has attended Balint type groups
and has had some training in small group leadership. Such a leader would need to have an interest in the
clinical area of the participants (e.g. general practice).

3. Group members are in clinical contact with patient

Members are usually GPs or GP trainees but groups have been run perfectly well for medical students,
nurses, psychosexual counselors etc.

4. The material of the group is based on the presentation of current cases giving the
presenting clinician cause for thought
The cases may have given rise to distress, puzzlement, difficulty or just surprise. Random cases have
occasionally been used (even in groups run by Michael Balint) but we would not recommend this for
‘starter’ groups.

5. The discussion focuses on the relationship between the presenting doctor and
his patient
Matters of ‘fact’ may need to be cleared up at points during the discussion but only those that have a
bearing on the doctor/patient relationship are relevant. Discussion of general issues is also not relevant.

6. Case notes should not be used

The presenting doctor may prepare himself with reference to the case notes. In the actual presentation and
discussion relying on memory is crucial. Slips of memory are not considered as signs of poor doctoring
but as vital clues to the understanding of the patient.

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 400  Family Medicine: A Clinical and Applied Orientation
7. The groups are not for personal therapy
Self-awareness will increase as a result of attending a Balint group but the discussion is firmly focused
on the patient and the doctor/patient relationship ‘Discomfort or distress in the doctor are not ignored
but are worked through in the context of the needs and problems of the patient rather than of the doctor.1

8. Standard rules for small group working apply

Confidentiality, honesty, ownership, respect for other group members etc. are essential. Group members
should be arranged in a circle, preferably on chairs of similar size. Each group session should normally
last between one and two hours. Usually, the discussion of each new case lasts between half an hour and
an hour.

9. The purpose of the group is to increase understanding of the patient’s problems,

not to find solutions (Paraphrased from Campkin, 1986)
Participants are therefore encouraged to speculate as to how they see what might be going on. Questions
are discouraged. Advice is discouraged even more.

10. The leader takes ultimate responsibility for trying to ensure that the group
functions as described above
Group members should also have a responsibility (see 8 above). The leader must above all ensure that
group members, particularly the presenter, are not unduly hurt (Some increase in anxiety on the other
hand, is an almost inevitable concomitant of learning).

DESIRABLE CHARACTERISTICS OF A BALINT GROUP

1. The group is ‘ongoing’
The original Balint groups used to meet weekly over several years. Nowadays, this is usually unrealistic but
a commitment to regular meetings is important. On the other hand, even a single session can be enough
to taste the method and attendance at, say, a Balint Society weekend can lead to some useful learning.

2. The group is closed

It is best if the group membership is unchanged for much of the time. On the other hand, in the real world
of, say, GP training, carousel groups are much better than nothing.

3. There is a co-leader
Joint leadership by a GP and an analytically oriented leader or by an experienced leader and a leader in
training gives added value to the group.

4. The leader has psychoanalytical training

Common sense suggests that a leader with a facility of understanding the unconscious is likely to help
participants more effectively to understand the doctor/patient relationship. On the other hand, good small
group leadership skills are probably even more important than analytical training. Experience of coleading
with an analytically oriented leader is obviously useful too.

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 Appendices 401

5. The group does not have to include all-comers

Ideally leader(s) should interview potential participants beforehand but groups of ‘conscripted’ trainees,
for example, can work very well. It could be argued that those with insufficient flexibility to contribute
usefully to a Balint group may have major problems with clinical practice.

Reference
1. Campkin M. Is there a place for Balint in vocational training? Journal of the Association of Course
Organizers. 1986;1:100-4. (Compiled, after consultation with other members of the Balint Society
council by Paul Sackin, vice president of the British Balint Society).

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 402  Family Medicine: A Clinical and Applied Orientation
Appendix 5B
Michael Balint: Biography

Michael Balint
Hungarian psychoanalyst and biochemist, 1896-1970.

Associated Eponyms
Balint group
Self-help group for people mainly formed by a small number of doctors interested in improving their
relationships with their patients and coordinated by a especially trained psychiatrist.

Biography
Michael Balint was born Mihály Maurice Bergmann, the son of a practising physician in Budapest,
Hungary, on December 3, 1896. It was against his father’s will that he changed his name to Michael Balint.
He also changed religion, from Judaism to Unitarian Christianity. During World War I Balint served at the
front, first in Russia, then in the Dolomites. He completed his medical study in Budapest in 1918. On the
recommendation of his future wife, Alice Székely-Kovács, Balint read Sigmund Freud’s “Drei Abhandlungen
zur Sexualtheorie” (1905) and “Totem und Tabu”.
He also began attending the lectures of Sándor Ferenczi, who in 1919 became the world’s first university
professor of psychoanalysis.
Balint married Alice Székely-Kovács and about 1920, the couple moved to Berlin, where Balint worked
in the biochemical laboratory of Otto Heinrich Warburg (1883-1970), the later (1931) Nobel Prize recipient.
His wife worked in a folklore museum. Balint now worked on his doctorate in biochemistry, while also
working half time at the Berlin Institute of Psychoanalysis. Both Michael and his wife Alice in this period
were educated in psychoanalysis.
In 1924, the Balints returned to Budapest, where he soon assumed a leading role in Hungarian psycho-
analysis. During the 1930s, the political conditions in Hungary made the teaching of psychotherapy
practically impossible, and they emigrated to Manchester, England. Here, Alice died in 1938, leaving Balint
with their son John. In 1944 Balint remarried, but the relationship soon ended, although, they were not
divorced until 1952. In 1945 his parents, about to be arrested by the Nazis in Hungary, committed suicide.
That year Balint moved from Manchester to London, continuing his group work with practicing physicians,
and obtaining the Master of Science degree in psychology.
In 1949, Balint met his future wife Enid Flora Eichholz, who worked in the Tavistock Institute of Human
Relations with a group of social workers and psychologists on the idea of investigating marital problems.
Michael Balint became the leader of this group and together they develop what is now known as the Balint
group. The first group of practicing physicians was established in 1950. Michael and Enid married in 1958.
In 1968 Balint became president of the British Psychoanalytical Society, the chair, he continued to serve
until his death on December 31, 1970.

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 Appendices 403

Appendix 6
BASIC GERIATRIC HEALTH QUESTIONNAIRE
NAME: DATE:
Yes/No
Questionnaire Please tick Please give details
1. Compared with two years ago:
–– Is your sight poorer? —
–– Is your hearing poorer? —
–– Do you feel more tired? —
–– Has your weight changed? —
–– Are you more breathless? —
–– Do you pass water more often— —
–– especially at night?
–– Can you move about as freely? —
–– Is your memory poorer
- for recent events? —
- for events long ago? —
–– Is your concentration poorer? —
2. Do you have any of the following:
–– Anxiety —
–– Depression —
–– Dizzy spells —
–– Blackouts —
–– Insomnia —
–– Pains in:
- head —
- abdomen —
- legs on walking —
–– Breathlessness —
–– Persistent cough —
–– Indigestion —
–– Constipation or diarrhea —
–– Wetting —
–– Swollen ankles —
–– Foot problems —
–– Pain or swelling of joints —
3. Can you move about as well as 12 months ago? —
4. Have you been in hospital in the past years? —
5. Have you any other health problem? —

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 404  Family Medicine: A Clinical and Applied Orientation
Health problems*
1. Medical disorders Action recommended*
a. Need for:
b. 1. Doctor
c. 2. Nurse
d. 3. Health visitor
e. 4. Chiropodist
2. Socioeconomic problems 5. Physiotherapist
a. 6. Occupational therapist
b. 7. Social worker
c. 8. Voluntary worker
d. 9. Other for e.g.
e. cutlery fittings, meals on wheels,
f. more home, help time etc.
g.
h.
3. Disabilities
a.   b.   c.
.....................................................................................
Adaptation–good fair poor
.....................................................................................
Next of kin–Address/Telephone

.....................................................................................
Relatives/friends
prepared to help in crisis–Address/Telephone
.....................................................................................

.....................................................................................
Welfare representative Risk index–Please Tick*
Address/Telephone Medical problems Socioeconomic
1. Nil Nil
2.   Minor Minor
3. Major Major
4. Dependent
5.  Wholly dependent

* to be assessed/filled by health professional.

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 Appendices 405

Appendix 7
distance Education Program

Distance education program for physicians to become “physician leaders in healthcare” - JIMA.
2011;109(3):p.ii.

Value-Add
Apollo and ACPE Offer Post-Graduate Diploma in Advanced Physician Leadership.
The program consists of 14 courses totaling 150 credit hours, covering subjects relating to professional
management of hospital and healthcare organizations.
In order to meet the growing demand for formally trained physician executives in India, Apollo
Hospitals Group, Asia’s largest corporate healthcare organization, in association with the American College
of Physician Executives (ACPE) of USA will offer Asia’s first postgraduate Diploma in Advanced Physician
Leadership (PGD-APL) program.
ACPE (www.acpe.org) has been in operation in the US and Canada since 1975. It originated at the
Medical School of the University of Wisconsin, Madison and has demonstrated expertise in adapting the
distance education model.
PGD-APL program is exclusively for physicians. It can be completed in 1 year through fully supportive
interactive and distance education modes. The program consists of 14 courses totaling 150 credit hours,
covering subjects relating to professional management of hospital and healthcare organizations.
The program is scheduled to start in the second half of 2010. The unique features of the program
include opportunity to pursue education regardless of location with internet connection, at ones own
convenience, secure international exposure in healthcare, developing professional network and special
interest groups, as well as membership in ACPE.
Medical graduates holding MBBS and a valid Medical Council of India/State Medical Council
registration with 3 years clinical and 1 year of management experience are eligible to enroll in the program.
The program is of immediate benefit to physicians, who are aspiring to become physician executive to lead
the stand-alone, corporate, trust, public sector hospitals, healthcare and hospital consultancy organizations.
The opportunity for physician executives will open unprecedented opportunities in India’s dynamic healthcare
industry and abroad.
Hospital and health organizations can build their physician leadership by sponsoring their promising
and high caliber physicians to be groomed for leadership positions in the organization.
The program includes ACPE member­ship, course materials and 1-week contact program. Assistance for
educational loans from nationalized banks in India will be explored. Placement assistance will be provided
upon successful completion of PGD-APL.

CONTACT: Prof Habeeb Ghatala, Dean

Apollo Hospitals Educational and Research Foundation
Apollo Health City,
Jubilee Hills, Hyderabad
Andhra Pradesh, India
Mobile: +91 99484 40701 (24 × 7)
Email: habeeb_ghatala@apollohospitals.com/habeeb.ghatala@gmail.com

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 Index

Page numbers followed by f refer to figure and t refer to table

A Autonomic neuropathy 278

Ayurveda 144
Acupuncture 144
Ayurvedic medicine 144
Adolescent care 221, 230
Adolescent communication 226
Adolescent consultation 223 B
Adolescent depression 235 Balint group 123, 124, 125t, 126t
Adolescent preventive services, guidelines for 229, Balint training 125
230 BATHE technique 46, 99, 100
Adverse drug incidents 362 Biofeedback 144
Aging and geriatric concepts 243 Biopsychosocial model 73, 307t
Agitation 310, 311 Blood pressure 255
Alexander technique 144 Bradyarrhythmia 278
Alma-ata Breath, shortness of 63
declaration 51, 52 Byrne and Long model 107
genesis of 52
American Academy of Family Physicians 15
American Academy of General Practice 15 C
American Academy of Physician Assistants 161 Calgary-Cambridge observation guide 97t
American Board of Family Practice 15 CAM, basic principles of 145t
American College of Cardiology Foundation 273t, Canal stenosis 277
350 Cancer
American Heart Association 273t, 350 breast 340
Anemia 278 cervical 340
Antenatal care 338 colorectal 340
Anticonvulsants 278 prostate 340
Anxiety 63, 349 Caplan’s model of crisis intervention 44
Appreciation 38 Cardiovascular disease 272t
Aromatherapy 144 Carotid sinus sensitivity 278
Ashtanga Hridaya Samhita 116 Charaka Samhita 116
Attitudes 88, 280 Chest infection 245
Audit cycle 361, 362f, 365 Chronic diseases 284t
steps in 363f Clinical audit 359-361
Audition 89 Clinical research 392

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 408 Family Medicine: A Clinical and Applied Orientation
Cognitive impairment 286 Dizziness 63
Cohort study 387 Doctor-centered method 106
Communication 92, 93, 313 Drug compliance 323
barriers in 93 Dry/sore mouth 311
pitfalls 95 Dyspepsia 311
skills 87, 203, 215, 351 Dysphagia 312
strategies 156 Dyspnea 311
techniques 226
types 91 E
Comprehensive geriatric functional assessment,
components of 250f EBM
Computerized disease-specific health system 178 curriculum, lack of 379
Conducting whispered voice test 256t limitation of 373
Confidence, lack of 351 Electronic medical records 101, 178
Confidentiality 120, 224, 365 Emotional support 324
Confusion 268, 310, 311 Empathy 202
Congestive heart failure 278 Errors, types of 171
Constipation 311 Establish advisory board 163
Consultation process 106 Establish network 163
Consultation room 132 Establish patient safety center 178
Conveying acceptance 137 Establish rapport 118
Coping skills for physicians 202, 204 Evidence-based clinical decision, model for 381f
Cost-conscious profession 58 Evidence-based medicine 367, 369
Cough 63 learning of 367
Counseling 136, 191, 228, 228 practice 376
procedure 139 principles 366
skills 136 Evidence-based practice, domain of 376f
strategies 140 Extreme fatigue 311
errors of 138
Cross-sectional study 386 F
Cultivate sense of partnership 201
Family-based medical counselling 46
Cultural issues 389
Family counseling 138
Current health status 252
Family dynamics and illness 41
Family health care 37
D system 154f
Daily life, instrumental activities of 261 Family life cycle 39
Daily living, activities of 259 Family medicine 10f, 12, 19t, 20, 37, 390
Death rattles 311 philosophy of 3
Delirium 268, 269, 270t, 311 research in 384, 390
toxic causes of 271t revival of 15
Dementia 246, 268, 270t, 278 scope of 8
of Alzheimer’s type 268t Family physicians 30, 130, 138, 330
Demoralization syndrome 319, 319t attributes of 30
Depression 44, 63, 236t, 246, 268, 269 involvement of 320
signs and symptoms of 252t proactive role of 10
Develop and maintain support system 164 role of 39, 244
Diabetes mellitus 276 Family practice 18, 31, 70t, 389
Diet therapy 144 Binary tree decision in 71

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 Index 409
matrix of 9 Hyperglycemia 278
prevention in 335 Hypertension, borderline 189
Fatigue 63 Hyperthyroidism 257t, 276
Fever 277 Hypnosis 144
Fibromyalgia 277 Hypoglycemia 278
Flexibility 38 Hypotension 278
Functional geriatric screening instrument 261t Hypothesis 76
Fundamental ethical principles 211 Hypothyroid coma 276
Hypothyroidism 257, 275
G
Gastrointestinal problems 274
I
General Medical Council 13 Immunization, childhood 341
General practice 22, 31 Incontinence 246, 258
consulting models in 107t Insomnia 63
General practitioner 29, 123 Intermittent delirium 278
General strategies 94 Interview, main part of 110
Geriatric care Intestinal obstruction 312
and family physician 265
paucity of 265 J
Get up and go test 258t Joint pain 277
Gold standard tests 82
Good counsellor, qualities of 137
Gout 277
K
Grief 327 Karnofsky performance status 308t
complicated 330
course of 329 L
features of 328 Laboratory testing cycle 78f
normal 329 Leaders maintain integrity 162
reaction, types of 329 Leadership 159, 162, 164
symptoms of 328 Licentiate of Society of Apothecaries 14
Group discussion 163 Liver disease 286
Growth 39
concerns 228
M
Malignancy 245, 277, 278
H Manipulative help-rejecters 198
Harness power of self-control 203 Maturity 214
Headache 63, 189 Medical assessment 251
Health education 342 Medical audit 189, 360
Health insurance examination 338 Medical Council of India 191
Health maintenance organizations 35, 98 Medical decision making 191
Health promotion and disease prevention 341 Medical education, reorientation of 20
Healthy communication 38 Medical errors 169
Healthy family 38 types of 171t
Hearing deficits 94 Medical professionalism 208
Hearing loss 246 Medical record 184
Hearing problems 279 importance of 191
Heart failure 286 purpose of 184t

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 410 Family Medicine: A Clinical and Applied Orientation
Medicine, complementary and alternative 144t P
Medicolegal records 192
Pain 310-312
Meditation 144
abdominal 63
Ménière’s disease 278
back 63
Mental and emotional evaluation 252
bone 277
Mental status examination 259
Message therapy 144 chest 63
Migraine 189 controlling 322
Morbidity data, collection of 392 muscle 277
Morphine, massive doses of 312 musculoskeletal 277t
Multiprofessional clinical audit in family practice night 277
361 tendon and ligament 277
Musculoskeletal pain Palliative care 303-304, 316, 321
causes of 277t principles of 306, 307t
types of 277t scope of 306f
Musculoskeletal problems 276 Parenting stress 233
Musculoskeletal stiffness 246 Parkinson’s disease 278
Myelopathy 278 Payment system 351
Myocardial infraction 278 Pendleton, Schofield, Tate and Havelock model 107
Myxedema coma 276 Periodic health examination 338
Permissive parenting style 234
N Personal autonomy 38
National Cholesterol Education Program 350 Personality disorders, borderline 123
Naturopathy 144 PHC
Nausea 311, 312 concept of 56
Negative predictive value 80 ingredients of 57
NICE guidelines 362 Physician’s plan 188
Noisy breathing 311 Physician’s role 45, 237, 266
Noncommunicable diseases 136, 346 Polymyalgia rheumatic 277
Non-drug therapy 287 POMR, limitations of 190
Non-judgmental listening 203 Positive predictive value 80
Non-physician primary care providers 33 Postfall syndrome 277
Nonspecific abnormalities, normal occurrence Postnatal care 338
of 247 Potential personality disorder 202
Non-verbal aspects 120 Practice participatory care 100
Non-verbal communication 92 Preferred provider organizations 35, 98
Non-verbal skills 92f Primary care 28, 32
Numbness 44 physician 32
Nutrition 279, 324 practice 32
Nutritional therapy 144 Primary health care 52, 55, 59
genesis of 56
O Problem-oriented medical record 186
Olesen definition 24 Professionalism
Open-ended questions and body language 89 evolution of 209
Oral morphine 322t model behaviors of 214
Osteoarthritis 277 Pseudo gout 277
Osteopathic manipulative therapy 144 Psychological issues 313
Osteoporosis 277 Pulmonary embolism 278

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 Index 411

Q Sushruta Samhita 116

Syncope 278
Qualitative research 387, 388
Syringe driver 312t
Quantitative research 386, 388
System redesign in family practice 175

R T
Randomized controlled trials 387
Team training 154
Record keeping, purpose of 184
Ten leadership action steps 164t
Rectal route inappropriate 312
Terminal stage debility 312
Refining communication skills 98
Thyroid disease 245
Reiki 144
Traditional medical decision-making, sequence
Renal disease 286
of 368f
Research 361 Traditional medicine 144
logistics of 390, 391f Training, lack of 350
methodology, types of 386 Transient ischemic attacks 278
training 392 Tunnel” syndromes 277
Restlessness 310, 311
Rheumatoid arthritis 277
U
S United Nations Population Fund 221
Urinary incontinence 275t, 311
Safety and injury prevention 341 Urinary retention 311
Screening 338, 339
Sedatives 278
Seizures 278
V
Senile gait disorder 278 Vaginal discharge 63
Sensitivity 79 Verbal communication 91
Sepsis 278 Verbal skills 91f
Sexual dysfunction 63, 246 Visual field defects 278
Sexual practices 341 Visual impairment 278
Shock 44, 278 Vomiting 311, 312
Sick sinus syndrome 278
Silent myocardial infarction 245 W
Skills, interviewing 109
Waiting room and reception 131
Soft tissue rheumatism 277
Weed system 186, 188t, 189
Spiritual healing 144
World Health Organization 264
Spiritual support 324
Spoon feeding, limits of 165
Strategies, combination of 141 Y
Suicide warning signs 254t Yoga 144

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