SECTION 03

CONCEPTS OF FAMILY MEDICINE

1 Family Medicine In Health

Care Delivery
2 Personal Care, Continuing
Care & Comprehensive Care
3 Family As The Unit Of Care
4 Emergency House Calls &
Home Care
5 Palliative Care

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SECTION 03
SECTION 03 CONCEPTS OF FAMILY MEDICINE

CHAPTER 1 FAMILY MEDICINE IN

HEALTH CARE DELIVERY

Outline
Family Medicine As A Discipline
Place Of Family Medicine In The Health Care
Working Towards Unity
Knowledge, Skills and Attitudes in Practice
Disease Patterns
Organisation Of Care

FAMILY MEDICINE AS A DISCIPLINE

Family Medicine

Family Medicine is a discipline concerned with the provision of personal, primary,

comprehensive and continuing health care of the individual in relation to his family,
community and his environment.

The discipline may also be known by various other names, namely, "General Practice" or
"Primary care medicine". For practical purposes they mean the same thing. The term
“Family Medicine” is preferred to emphasise the family as the sociological unit providing
support to the individual as well as to reiterate the importance of the family in the cause
and effect of health and disease in the individual.

The Family Doctor

The family doctor and his work may be defined as follows:

The family doctor is a qualified medical practitioner who provides personal, primary,
comprehensive and continuing health care to his patients in relation to their families,
the community and their environment. He may attend to his patients in his clinic, in
their homes or sometimes in the hospital.

In treating his patients the medical practitioner must take into consideration the whole
person, their psyche as well as their body systems and must not treat just the signs
and symptoms.

In providing comprehensive and continuing care he will need to interact with his
medical and para-medical colleagues. In promoting his patients' health he will not
only treat therapeutically but also educate and counsel his patients.

The Central Values Of Family Medicine

As a worldwide movement, family medicine had its prelude in the growing disenchant-
ment of general practitioners and their patients with the fragmentation of care and

42
impersonal care brought about by subspecialisation and growth of high technology in
the 1960s.

There was clearly a need for a group of doctors to sound the warning of too much of
fragmentation as well as to address the consequences of this phenomenon. This was the
phase of counterculture (Stephens, 1998). The family physicians on both sides of the
Atlantic spearheaded the counterculture movement. Colleges of General Practice or
Family Medicine were formed. In 1972, the world body of family medicine, Wonca was
formed. The counterculture movement was become worldwide. Singapore and Canada
were the early members.

What are the central values of this counterculture to hospital specialist medicine?
There are six of them. We can remember them as 3 plus 3:

The first three are attitudes that we would want to infect all doctors with:
• Patient centred care and attention to the doctor-patient relationship.
• Holistic approach to the patient and his problems that recognizes contributions to ill-
health and well-being come from not only physical disease but equally if not more
from social and psychological dimensions in the patient (the bio-psycho-social model
of ill-health) as well as from the family and his community; family doctors have found
that paying attention to these are often effective in solving the physical health
problems; the specialists should know this too. Indeed, the studies of Prof Michael
Marmot on the staff of Whitehall in London proved beyond doubt the importance of
removing poverty in removing ill health. So the solution to good health actually lies
outside medicine. Doctors only help to fix those wounded, many by social and
economic circumstances.
• Emphasis on preventive medicine because this has greater long term impact on health
status than curative medicine.

The next three central values define the family doctor’s work:
• The family doctor looks after health problems that may be initially unclear in terms of
seriousness – the ability to deal with initially uncertain symptoms is important in the
makeup of the family physician.
• The family doctor looks after people across the whole spectrum of age groups – he is
a specialist in breadth, unlike the hospital specialist who is a specialist in depth.
• The family doctor is willing to look after the patient not only in the consulting room
but also in the home and other settings as well.

The need for a holistic worldview of the patient and his medical problems is greater than
ever today with high technology medicine threatening to dehumanize medicine and to
fragment patient care. Clearly a balance has to be made all the time.

Bio-psycho-social model of illness

Engel (Engel, 1980) is credited with the link of the three dimensions of health and ill-
health – the now well-known bio-psycho-social model of illness. It is important to
recognise that every illness has varying admixtures of physical, social and psychological
consequences. It is not enough to pay attention to the physical aspects only. In the

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hospital, the physical dimension assumes greater prominence; even then as the patient
recovers the social and psychological dimensions may assume greater prominence. In
general practice, a proportion of patients may have a social or psychological problems as
the underlying cause of ill health and these may be presented as physical complaints
(a phenomenon known as the hidden agenda).

The family as the unit of care

The family physician looks after more than one member of the family. The doctor gets to
know the health of the family as an unit. Also as the family goes through its family life
cycle, there are new tasks that the family has to complete. The family doctor is often
called to provide his advice and care.

THE PLACE OF FAMILY MEDICINE IN HEALTH CARE

Division of Labour

General Practice/Family Medicine is concerned with primary care (first contact care) whilst
the hospital is concerned with secondary and tertiary care. Such a division of labour is
cost effective on available health care resources.

A well developed General Practice/Family Medicine service will relieve the workload on
the hospital by looking after patients that could be managed outside the hospital:
• minor illnesses.
• post hospitalisation and rehabilitative care.
• terminal care that the hospital can no longer help.
• continuing care of chronic problems like hypertension, diabetes.
• care of conditions that can be done jointly with the hospital e.g., cardiovascular
disease, bone and joint problems, chronic skin problems.

At the point of first contact, cases not requiring hospital care are filtered out and treated
so that only appropriate cases are sent to the hospital. This of course will work only
if patients do not use the hospital A & E Department as a point of entry for
non-emergency care.

The prevention of communicable diseases by immunisation and opportunistic patient

education is best done at the outpatient level, e.g., measures to limit the spread of
conjunctivitis, measles and other infections.

Similarly, the prevention of non-communicable diseases related to lifestyle through health

education on nutrition, smoking, alcohol intake and pursuance of healthy habits can be
the family physician's responsibility.

Working Towards Unity for Health

The development of Family Medicine into what we know of it today has gone through
three phases (Scherger, 1997). We have dealt with the first phase of counterculture. From
this phase of counterculture in the 1970s and the second phase of parity (seeking
recogntion to be on par with the specialties) in the 1980s, family medicine has moved

44
into a new phase of intgration in the 1990s and into the present. Here, the prevailing
mood is for integration of clinical activities. The judgment call is whether family
departments would want to integrate with hospital based disciplines like paediatrics,
general internal medicine and even geriatrics. The danger is for departments of family
medicine to be left behind if they choose to stand alone. And what about integration
between family medicine and public health?

Integration of health care activities and providers is now the focus of health care reform in
Singapore. The formation of the 2-cluster system of health care, the concepts of seamless
care, disease management, stepped down care, and shifting the center of gravity to the
family physicians are steps in this direction. We would need to look into sustaining health
care needs of not only the present but in the future as well. And we need to remember
that eradication of poverty eradicates ill health. So health must integrate with social and
economic development of the country.

Where do we go from here? The lack of integration was the starting point for the family
medicine counterculture. Family medicine has the role of integrating in the mind of every
doctor the balance between specialization and generalist approach in the care of
patients. The organ subspecialist needs to see how his expertise fits into the total well-
being of the patient.

Specifically, we need to work on the following seven areas in our integrating efforts in
health care delivery. We can remember them as 4 plus 3:

The first 4 are processes of care

(1) Good preventive care – Preventive care must take the forefront of our care – the old
adage of “prevention is better than cure” will always remain true. We therefore need
to integrate preventive efforts in our curative work – this applies to the specialist too.
(2) Good acute care – Acute care is where we really need to integrate knowledge, skill
and experience and to share it with one another on how to do things right the first
time. It is not always easy and takes a lifetime to perfect. And good acute care is very,
very important in the elderly, particularly, in the very old because the window of
opportunity is small and we must act fast or they will never be the same again.
(3) Good chronic disease care management – attention to these will surely reduce the
burden of disease on the sufferers. Good chronic disease care is a good example of the
need for integrative care. That is why across the world, chronic disease care is still very
poor. And good integrated chronic disease care will make a big difference in the
reduction of disease burdens.
(4) Good step-down care – this is increasingly important with the rising cost of acute
hospital care and the increasing numbers of the elderly who take a longer time to
recover from their medical illnesses. Good step-down care again relies on integration.
It is a baton relay of care.

The next three concerns those where it is more care than cure
(5) Good elderly care – the care of the elderly is perhaps the best example of the need for
integrated care both vertically and horizontally. Care of these people cannot be
good without adopting the paradigm of integrating the efforts of carers for a
common purpose.

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SECTION 03 CONCEPTS OF FAMILY MEDICINE

(6) Good domiciliary care – this is a very much underserved area of care in many parts of
the world. It will grow in importance as an area of need as more and more people live
to ripe old age.
(7) Good palliative care – This will include not only terminal care but also the care that can
extend and enrich those with cancer who cannot be cured. Hope still springs eternal
when one day we may be able to slow down the destructiveness of cancers and give
the sufferers more life and longer life. The idea of controlling cancer just like
controlling diabetes mellitus may not be such a far-fetched idea. And good palliative
care goes beyond cancers. It is also needed to slow down the progression of end organ
disease states. Think of the end stage heart disease, kidney failure and stokes. The care
is all palliative.

KNOWLEDGE AND SKILLS REQUIRED IN PRACTICE

Knowledge

The family doctor working in any community requires three types of knowledge:

Basic clinical knowledge

This is the most essential area and has three broad elements:
• The natural history of disease. Part of this is encountered in the hospital context;
the early part of the natural history of diseases often may be seen only in the family
physician clinic.
• Human development. A sound knowledge is necessary to differentiate between
normal and abnormal development.
• Human behaviour. Some knowledge of human behaviour is covered in medical
sociology and psychological medicine. In general practice, the doctor encounters
examples of human illness behaviour that are specific to general practice.

Knowledge of patient community & changing trends

Knowing the community is important. Each community has its cultural, ethnic, economic
characteristics that may be relevant to practice. Demographic changes are associated with
new health care needs and priorities. With better literacy and health, there is an
increasing demand for patient participation in medical decision making.

Knowledge of professional community & changing trends

Medical practice today requires the support of various services and the health care team.
The doctor in practice must know the services that are available for his patients. Such
services may change as medical technology changes.

Examples of such required knowledge are:

• Knowledge of existing and new services provided by the laboratory, the hospital
such as that of, the day surgery centre, oncology centre, dialysis centre, to name
some examples.
• Knowledge of emerging community facilities like day care centres, old folks homes,
and the hospice.
• Knowledge of services available from physiotherapists, dietitians, and specialist colleagues.

46
Skills

The doctor requires four types of skills to be an effective family doctor.

General clinical skills, practical and procedural skills

General clinical skills include history taking, physical examination and simple laboratory
skills learnt in the hospital postings. Practical and procedural skills are skills that include
operative skills, orthopaedic manipulative skills etc. learnt during both undergraduate and
postgraduate training.

Special clinical skills of importance to general practice

There are a number of special skills important to general practice. These are:
• Doctor-patient relationship – This is the vehicle for caring to take place
• Communication of facts, ideas, views and concerns – This allows sharing to take place
on what action needs to be taken to deal with a particular problem.
• Counselling and health education – These skills empower and build capacity for the
patient to resolve conflicts and dysfunction; to provide self-care, lifestyle modification,
and care of family members.
• Skills in managing special groups of patients – Patients with a chronic problems,
the terminally ill, the bed-ridden patient, patients with problems of living, and
the members of at risk families, all require special skills for caring for these
people competently.
• The solution of undifferentiated problems – The family physician sees problems at its
earliest stages. It is through continuity of care, the appropriate use of time as a tool,
appropriate investigations and sometimes referral for observation that such problems
become resolved.
• The identification of risks and early departures from normality – This helps to identify
diseases in patients who are known to the family physician e.g., loss of weight, pallor,
changing complexion may be picked up by the observant family physician.

Skills in resource management

As a generalist and first-contact physician, the family physician has control of large
resources. He is able, within certain limits, to control admissions to hospital, use of
investigations, prescription of treatment, and referral to specialists. In most parts of the
world, resources are now limited. It is therefore, the family physician's responsibility to
manage these resources for the maximum benefit of his patients.

Practical management skills

These are necessary because most family physicians are managers to their clinics. Only the
very large practices employ professional managers.

DISEASE PATTERNS IN GENERAL PRACTICE

Knowledge of the disease pattern of cases in general practice is important in order to

make the correct diagnosis. As a generalization, the family physician sees medical
problems that are largely self-limiting and his task is to confirm this is so, provide the
necessary reassurance and treatment to resolve the symptoms. He needs to be vigilant
however, to spot the serious problems early enough for action to be effective.

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SECTION 03 CONCEPTS OF FAMILY MEDICINE

Communicable diseases have receded in importance as the environment and water

supply is made safe from pollution by human discharges, and immunization for many of
the airborne childhood diseases. Nevertheless, the influx of people from other countries
for work or travel means that we have to continue to be vigilant.

One-Day Morbidity Study

One way of determining the disease patterns of the community is through a One-Day
Morbidity Study. The figures from such studies in Singapore as examples are given in
Tables 1 and 2.

Table 1. Leading Conditions seen at Private General Practitioner

Clinics and Primary Health Care Clinics 1998 in Singapore (One-Day
Morbidity Survey, 1998)
General Practitioner Clinics Primary Health Care Clinics
Rank Condition Percentage of Condition Percentage of
all Attendances all Attendances
1 Upper respiratory 33.6 Upper respiratory 27.9
tract infections tract infections
2 Arthritic conditions/ 6.1 Hypertensive disease 12.4
rheumatism
3 Dermatological 5.7 Diabetes mellitus 8.0
disorders
4 Diarrhoeal diseases 5.2 Dermatological 5.3
disorders
5 Hypertensive diseases 5.1 Diarrhoeal diseases 3.6
6 Asthma, Bronchitis, 4.8 Arthritic conditions/ 3.5
and Emphysema rheumatism
7 Gastritis 2.7 Asthma, Bronchitis, 3.1
and Emphysema; Tuberculosis
8 Diabetes mellitus 2.1 Conjunctivitis 1.8
9 Conjunctivitis 1.4 Gastritis 1.2
10 Neurotic disorders 1.1 Ill-defined conditions 6.5
Ill-defined conditions 9.1
Others 24.1 Others 24.3

Table 2. The Relative Frequency of Presenting Problems in Family

Practice (Singapore)
Paediatric Adult Overall

Cough 14.4% Cough 7.1% Cough 9.1%

Fever 11.5% Nausea & vomiting 4.8% Sore throat 5.4%
Sore throat 7.3% Sore throat 4.7% Nausea & vomiting 4.8%
Lower ext. pain 4.1% Fever 4.4% Vomiting 4.7%
Cold 4.1% Headache 3.6% Cold 3.3%
Nasal discharge 4.0% Chest pain 3.5% Lower ext. pain 3.2%
Earache 3.6% Fever 3.3% Headache 3.1%
Abdomen pain 2.3% Back pain 3.3% Abdomen pain 3.1%
Diarrhoea 1.9% Abdomen pain 3.3% Upper ext. pain 2.8%
Headache 1.7% Cold 3.0% Chest pain 2.5%
Nasal stuffiness 1.5% Fatigue 2.0% Back pain 2.5%
Others 43% Dizziness 1.6% Fatigue 1.6%
Dyspnoea 1.4% Nasal discharge 1.6%

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 Table 2. The Relative Frequency of Presenting Problems in Family
Practice (Singapore) - Cont’d
Paediatric Adult Overall

Earache 1.5%
Diarrhoea 1.4%
Nasal stuffiness 1.3%
Dizziness 1.2%
Dyspnoea 1.2%
Other 46%

The disease patterns seen in individual clinics depends on several demographic factors in
the provider namely, age, sex, education, postgraduate training, personal and social
lifestyles, attitudes and interests, and experience, geographical location, consultation
hours and whether it is private or public institutions. The differences in incidence of
disease in the latter can be seen from a study of Table 1. The incidence of various medical
conditions also depend on age o the patient as is shown in Table 2.

ORGANISATION OF CARE
An integrated approach to the organization of care is important. Family Physicians are
in the best position to work towards the linking up of primary, secondary and tertiary
care services into a seamless network for the patient to move to and fro depending on
the stage of disease and management. This is a big challenge in any healthcare
delivery system.

Further reading
1. Stephens GG. Family Medicine as Counterculture. Family Medicine Teacher 1979; 11(5):14-8 (Reprinted in Fam
Med 1998;3(9):629-36)
2. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry 1980;137:535044.
3. Scherger JE. Phase Three of Academic Family Medicine. Family Medicine 1997; 29(6):439-440.

CHAPTER 2 PERSONAL CARE, PRIMARY CARE,

CONTINUING CARE, &
COMPREHENSIVE CARE

Outline
Personal care
Primary care
Continuing care
Comprehensive care

PERSONAL CARE

This is care that is delivered with a close rapport between the patient and the doctor.
The patient may consult his family doctor not only when he is unwell but may seek his
counsel as a friend and mentor.

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PRIMARY CARE

This is first contact care. In primary care, the patient may present with one or more of the
following reasons (reasons for encounter):
• pain or other symptom.
• accident and emergency.
• preventive health care.
• administrative requirements – physical check-up and certification.
• seeking assurance (worry about the meaning of symptoms).
• problems of living.
• legitimatisation of sick role.

Of these different reasons for encounter, acute care and preventive are the predominant
area of care. Some of the acute problems may be undifferentiated problems, meaning
that they could be self-limiting problems or they could be early presentations of serious
problems. For example, the abdominal pain is often due to a gastroenteritis but in some it
could be a symptom of appendicitis and in the woman, it could be an ectopic pregnancy.
For such situations, time is a useful tool to help the family physician come to a definitive
answer, provided the patient is well enough. This is where continuity of care (that is care
of an episode of illness by the same doctor) becomes important.

Two points need to be made: (a) The meaning of primary care here is clinically oriented
and is narrower than the wider scope WHO's elements of primary care; (b) what is seen by
the family physician is dependent on the decision of the patient – the patient may choose
to see the specialist or the GP or self-medicate or do nothing about it.

CONTINUING CARE

Continuing care is care of a chronic medical problem which requires regular monitoring
and also care of complications that may arise. This care may be provided by the same
doctor entirely, or the doctor functions as a member of the team. The basic requirement
is the presence of a care plan for the problem. Examples of medical conditions requiring
continuing care are: hypertension, diabetes mellitus, and hyperlipidemia.

In chronic medical conditions, continuity of care may not be always feasible. Hence, it is
important that there is good medical record keeping, communication and discussion of
the care plan.

There is also the need to introduce the concept of team care here. The members of this
team consists of the family physician as the coordinator of care, the specialist who sees
the patient time and again to deal with complications or to conduct a periodic review of
the health status of the patient. Then there is the nurse practitioner who counsels and
assists the doctor is looking after the patient; the dietitian; the physiotherapist,
and others. For those who are bedridden, the domiciliary care staff will need to be
activated. There may also come a time where the patient can no longer be suitable to be
looked after at home for various reasons like the absence of a carer or nursing has to be
done frequently – this is where the community hospital and nursing home comes into the

50
picture. Chronic medical conditions can be expensive and many may need financial
assistance. This is where the medical social worker may also need to be drawn into
the team.

How can Continuing Care be Encouraged?

Doctor - Patient relationship

In the care of patients with chronic problems, establishing a good doctor-patient
relationship is essential. This will ensure that patients comply with management strategies
and instruction on life-style changes, medication, etc. The provision of good personal care
by the doctor is important in maintaining a long-term relationship with the patient.

Consultation tasks
Pendleton’s list of ‘consultation tasks’ provides a good framework for the holistic care of
patients with chronic problems. Some of these are: Achieving a shared understanding of
the problem with the patient; Choose, with the patient’s agreement, an appropriate
action for each problem; Involve the patient in the management and encourage him to
accept appropriate responsibility for his care.

Consultation time
In patients presenting with acute problems or requesting for non-illness related consulta-
tions, the physician should take the opportunity to review any continuing problems
present, and the current state of management of these problems. The lack of time is the
main constraint, and to make time for the patient requires interest and professional
discipline on the part of the physician.

Health education
Patients with chronic problems should be educated regarding the benefits of life-style
changes, compliance with management strategies, regular follow-up care.

Patients should also be taught what to do in the event of an acute illness which may or
may not be related to the chronic illness. In addition, they should be alerted as to the
symptoms which may signal the beginning of any complication, and when to seek
medical help.

Methods Which Facilitate Continuing Care

Medical records
Proper documentation is necessary for efficient continuing care, as well as for medico-
legal purposes. Medical information should be systematically and legibly recorded, and
should reflect the patient’s main problems, findings, treatment and any future plans. They
should also include any special features of note, such as drug allergies, G6PD deficiency,
etc. Problem-orientated medical records. Computer recording systems are recommended
for efficiency of filing and retrieval.

Appointment and recall system

This is essential in the tracking of patients who come for regular follow-up visits.

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Any patient who misses an appointment should be sent a reminder or contacted through
‘phone. The use of computer systems will make this simple and routine.

In group practices, the use of appointment systems will also ensure that patients get to
see their regular doctor as much as possible, as appointments can be rescheduled when
the doctor goes on leave.

Clinic hours and staff orientation

The extension of clinic-opening hours to evenings and weekends, to accommodate
patients with regular working hours and their family members, would greatly facilitate
regular follow-up. Advance notice of any change in clinic hours should be given.

Clinic staff should be orientated towards facilitating continuing care, in that patients with
appointments should be given priority over walk-in patients, when they are punctual for
their appointments. Trained staff can also reinforce any health advice given by the doctor.

Compliance in Continuing Care

Compliance is defined as the extent to which a person’s behaviour (in terms of keeping
appointments, taking medications, and executing lifestyle changes) coincides with
medical advice. (Haynes et al)

Factors influencing compliance

The patient
(a) Socio-demographic characteristics e.g. age, gender, ethnic group.
(b) Attitude towards illness, health care provider, medical treatment.
(c) Knowledge about illness and its treatment.

The disease
(a) Increasing severity of disease is associated with better compliance.
(b) Chronicity of disease condition lowers compliance.

The treatment
(a) Treatment regimens that require behavioural changes are usually associated with
poor compliance, e.g. change in eating habits, exercising, stopping smoking.
(b) The greater the number of drugs prescribed, the poorer the compliance.
(c) Complicated dosage regimens also result in poor compliance.
(d) Method of drug administration, e.g. by injection, affects compliance.
(e) Unpleasant drug side effects may cause a patient not to take certain medications
(f) Cost of treatment is often a barrier for continuation of treatment.

The physician
(a) Physician prescribing habits.
(b) Physician attitude towards patient and his illness, i.e. type of care, doctor
patient relationship.

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Detection of poor compliance

Clinical judgment
From studies conducted, this has been shown to be unreliable, regardless of the type of
relationship the doctor has with his patient.

Monitoring attendance
Patients who default follow-up appointments are usually non-compliant, though the
reverse need not be true.

Response to treatment
Failure to respond to treatment can be used as an indicator of compliance, though this is
again not infallible. Some patients who respond to treatment may be doing so because of
over prescribing rather than good compliance. Conversely, patients who do not respond
to treatment may be because the dosage prescribed is inadequate.

Asking the patient

Not always reliable. Even under optimal interview conditions, about half of non-compliant
patients will deny the fact.

Counting pills
Useful research tool, though not very practical for clinical purposes. Counting pills in the
clinic usually results in bias in the direction of overestimating compliance. In general, pill
counts give higher estimates of compliance than quantitative drug assays and lower
(but more accurate) estimates than patient self-reports.

Drug levels
Useful in drugs with long half-lives resulting in relatively steady serum levels,
e.g. phenytoin, digoxin, theophylline, but not so good for drugs with short half-lives.
Caution: individual variation in drug absorption, metabolism and excretion.

Prevention and treatment of poor compliance

Prevention
(a) Remove barriers to compliance e.g. Reduce waiting time, convenient appointment
schedule, simplify drug regimen.
(b) Involve patients in their care.

Treatment
(a) Trace defaulters.
(b) Increase attention and supervision.
(c) Use positive reinforcement, give encouragement.

Spectrum of Continuing Care

The spectrum of continuing care in Family Medicine is wide, and ranges from patients
who are very young to those who are very old and those who are terminally ill.

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Family physicians look after patients with a variety of chronic problems. These include
medical conditions such as hypertension, diabetes mellitus, bronchial asthma, stroke,
Parkinson’s disease, epilepsy; psychological problems such as depression, anxiety; and
terminal conditions such as cancer.

COMPREHENSIVE CARE

Comprehensive care has three meanings: (a) comprehensive in that it cares for all age
groups; (b) comprehensive in that it spans promotive, preventive, curative, rehabilitative
and palliative care; and (c) comprehensive in that it deals not only with the physical but
also social and psychological problems (that is, whole person medicine).

This one of the core values of the family physician. He is willing to look after patients in
one or more of the dimensions of comprehensiveness.

Stott-Davis Consultation Framework

Doctors need a good aide memoire to remind them of the potential of the consultation to
provide comprehensive care. Out of the understanding of the patient and his or her
clinical problem, comes a series of potential operational tasks for the doctor to perform.
Which will be performed depends to a large measure on time available, then knowledge
and skills, then awareness. These operational tasks have been described and organized
into a framework by Stott and Davies which they published in a paper in the J RCGP in
1979 titled the potential in each primary care consultation – an aide me moiré (Stott and
Davies, 1979)

The four operational tasks are shown in Figure 1.

Figure 1. Stott-Davis Consultation Framework
A B
Management of presenting problems Modification of help-seeking behaviour
C D
Management of continuing problems Opportunistic Health promotion

Task A – Management of presenting problems – Every consultation needs to address this

area. Besides, dealing with the presenting problems, it is good practice to embark on the
other tasks as far as time permits.

Task B – Modification of help-seeking behaviour – It may be necessary on occasion to

change the help-seeking behaviour. For example, the patient may insist on antibiotics
which are not appropriate. The modification of such behaviour needs due attention to
ideas, concerns and expectations behind the help-seeking behaviour.

Task C – Management of chronic problems – There is a need to address the care of

chronic problems whenever the patient visits. Time spent in this task will result in better
compliance and reduce complications from chronic diseases.

54
Task D – Opportunistic health promotion – Much can be done to reduce the onset of
disease related to adverse life-style. However, this is a challenging task because the
adoption of healthy behaviours require the change of life-long habits.

Extending The Stott Davis Consultation Framework to Home Care

The Stott Davis Consultation Framework can be extended to home care for the frail
elderly by including two more areas, namely environmental assessment (E) and function
establishment. This is described below.

Task E: Environment assessment – The frail elderly is an organism in homeostasis with his
environment. The environment can be seen in 2 parts:
1. Physical environment – home setting.
2. Social environment – presence of a caregiver as well as financial condition.

For example, failure to thrive may be due to elderly being unable to access nutritious food
either because of physical contraints or lack of finance.

Task F: Function establishment – Establishing function is important in the frail elderly.

It allows for:
1. A baseline status.
2. Detecting of disease. E.g. any intellectual or functional decline may herald dementia /
depression or other illnesses requiring further investigations. Functional decline may be
the first indication of disease in the elderly.
3. Monitoring of response to intervention. E.g. functional improvement after treatment
of depression.

Function establishment looks at:

1. Cognition and mood – A commonly used simple score used locally for cognition
screening is the modified Abbreviated Mental Test (Table 1).

Table 1: Modified Abbreviated Mental Test

Age (+2)
Year of Birth
Address
Place
Time (+1 hour)
Current year
Recognises 2 persons
Prime Minister
3 Objects recall
Serial 20 – 3
Total Score /10
_________________________________
0-4 Probable cause; 5-6 Borderline; >7 Normal

2. ADL – activities of daily living – This refers to self-care tasks that a person performs in
the course of living to maintain cleanliness, hygiene, appearance, nutrition and

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mobility. ADL measures the ability to feed, toilet, transfer (getting in and out of bed),
bathe, dress, remain continent and walk.

3. IADL – instrumental activities of daily living – This refers to the more complex tasks
necessary to function in society and requires combination of physical and cognitive
activities easily remembered as SHAFT (Shopping; Household chores; Ability to
take medications on own; Finances – banking and handling money; Transport
and telephone).

Assessing of function may be through simple reporting from patient or caregiver. Simple
office test includes seeing patient “ get up and go” to see his mobility status. In a busy
outpatient consultation, the tasks will need to be spread out over several sessions. This
will make it less onerous and more manageable.
References for further reading
Stott and Davies. The potential in each primary care consultation – an aide-memoire. J RCGP, Apr 1979: 201-205.
Ong JE. The frail elderly, homecare and the GP. Sing Fam Physician 2002; 28(4):54-8

CHAPTER 3 FAMILY AS AN UNIT OF CARE

Outline
Who forms a family?
Functions
Family Life Cycle
Developmental Tasks
Family Influence On The Individual’s Health
Functional And Dysfunctional Families
Level of Physician Involvement
Family Dynamics

WHO FORMS A FAMILY?

The family is a small social system made up of individuals related to one another,
biologically or by reason of strong affections and loyalty, that comprises a permanent
household (or cluster of households) and persists over decades. Members enter through
birth, adoption, or marriage and leave by death; therefore, the roles of members change
over time and through the history of the groups.

FUNCTIONS OF THE FAMILY

Every family has five basic tasks. These are:

• Support of one another. This support can be physical, financial, social or emotional or
combination of these. The support is provided through an organised network of
interdependent family roles. The support stems from the emotional ties among
members of the family.

56
• Establishment of autonomy and independence for each member. The family
facilitates personal growth of individuals within the family. Each member has a defined
role within the family, as well as an individualised role that extends beyond the
boundaries of the family, into the society at large.

• Creation of rules that govern the conduct of family members. The family rules are
largely unwritten. They are established by an informal decision-making process. The
rules deals with privacy, interaction patterns, authority and decision making.

• Adaptation to change in the environment. The ability to adapt, change, and grow is
essential for the long-term progression through a family's life cycle. A change can be
first order or second order change. First order change is adaptation to change in the
environment not requiring much change in family structure e.g. the family’s move to a
new place. Second order change – This involves a fundamental change in the basic
family structure e.g. a family member leaving for study abroad.

• Communication with one another. Communication is the key function without which
other functions are not possible. This can be verbal, non-verbal, implied messages.
Many of these messages are unintelligible to outsiders.

FAMILY LIFE CYCLE

In the course of its development, the family goes through a number of predictable
transitions. Families are more vulnerable during the transition from one developmental
stage to another.

The physician with an understanding of individual development, can form good

hypotheses about problems that his patients are experiencing, and are thus able to help
family members prepare for these problems, and to help to solve them. The family life
cycle is conceptualized as being made up of stages. Figure 1 shows a family life cycle
made up eight stages (From Duvall, 1977).

FIGURE 1. FAMILY LIFE CYCLE

2
1. Married couples (without children).
2.5 2. Childbearing families
Yrs.
Yrs. 3.5 (oldest child, birth - 30 months).
10 to 15 + Yrs.
Years
3. Families with preschool children
1 2 (oldest child 30 months - 6 years).
8 3 4. Families with schoolchildren
7 Years
4 (oldest child 6 - 13 years).
5. Families with teenagers
5 (oldest child 13 - 20 years).
7 6. Families launching young adults
6 7 Years
(first child gone to last child leaving home).
15 + Years
7. Middle-aged parents
(empty nest to retirement).
8 Years
8. Aging family members
(retirement to death of both spouses).

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SECTION 03 CONCEPTS OF FAMILY MEDICINE

DEVELOPMENTAL TASKS IN THE FAMILY

Developmental tasks in fhe family have been defined by Duvall (1977) as tasks that arise
at a given stage in the life of the individual or family. The success at the completion of
each stage leads to happiness and success with later tasks. Failure of these tasks leads of
unhappiness, disapproval by society, and difficulty with later tasks. Conflict of
developmental tasks between family members lead to tensions in family life. One
example is the adolescent's need to achieve independence vs his parents' tasks of guiding
him to a responsible maturity.

THE FAMILY'S INFLUENCE ON THE INDIVIDUAL'S HEALTH

The family has five main influences on an individual's health, namely :

• Genetic influences
The family endows its genetic heritage to the individual and this includes genetically
transmitted diseases: single gene defects e.g. thalassaemia; chromosomal disorders
e.g. Down's syndrome; and multifactorial genetic influences e.g. diabetes mellitus.
A knowledge of the genetic influences is necessary for prenatal diagnosis,
genetic counselling; surveillance in anticipation of influences on the patient
e.g. familial cancers.

• Influence on diseases
Transmissible diseases may be disseminated from one member to another
e.g. streptococcal sore throat, viral conjunctivitis, worm infestations. Increased risk of
neurotic illness in family members of neurotic patients.

• Influence on child development

There is evidence of relationship between family pathology and childhood disorders,
both physical (e.g. accidents, enuresis) and behavioural (e.g. aggression,
social withdrawal).

• Influence on morbidity and mortality in adults

There is well-documented increased mortality in widows and widowers during the first
year of bereavement. Bereavement is also associated with increased consultation rate
in family members. Clustering of visits may be an important cue to family problems.

• Influence on recovery from illness

Family support is an important factor in determining the outcome of all kinds of
illnesses, especially chronic illness and disability. Religious and cultural beliefs of family
members are also important determinants of coping and recovery.

FUNCTIONAL & DYSFUNCTIONAL FAMILIES

Physicians who follow the same patients over long periods of time come to recognise that
at the two extremes, are the happy and unhappy families. Most families, in reality, exhibit
fluctuating mixtures of happy and unhappy features. For this reason, the majority of
families have been referred to by researchers and family therapists as "mid-range

58
families". Each mid-range family has its own strengths and vulnerabilities. Physicians can
be most effective by helping families capitalise on their strengths and deal with their
vulnerabilities in healthier ways.

Characteristics of Functional Families (Happy Families)

Functional families radiate a sense of integrity and caring. Adult members espouse and
live by clear human values, express feelings appropriately, communicate effectively, and
share power while negotiating decisions.

All family members – children, adolescents, and adults – are encouraged to develop their
own life goals and emotional independence while staying connected with the family as a
whole. Functional families cope relatively well with adversity, often coming out of a crisis
stronger for the experience. Individual functional families differ widely, however, in how
they organise and conduct family life, and their members tend toward a healthy diversity
in many ways.

Characteristics of Dysfunctional Families (Unhappy Families)

Dysfunctional families, instead of integrity, radiate a sense of chaos or rigidity. There is a

high level of chronic underlying tension in such a family. Family members may adopt
personal values from authority figures, such as parents or clergy, or from friends or other
peers without considering their logical and emotional consistency. Alternatively, family
members may form values by reacting in opposition to the espoused or actual values of
influential people, again without critical analysis of their merits or drawbacks.

Communication tends to be chaotic, rigid or sparse, paralysing decision-making processes

and creating coercive power differentials between spouses and among family members.
Dysfunctional families tend to view individual differences and independence as disloyalty
that threatens their precarious emotional survival.

Such families have great difficulty dealing with stressors, expected and unexpected. Such
families can be caring when life circumstances are calm. When dysfunctional families are
stressed, their members tend to shift quickly from the caring mode into counterproduc-
tive modes of clinging, assaulting or escaping. When the levels of individual and family
anxiety rise, emotional reactions tend to override rational responses. They may express
intense feelings, many of which are negative. This style creates a heated family
atmosphere. At the opposite extreme, family members may shut off, blunt, or hide their
feelings, creating a cold atmosphere.

Despite their numerous liabilities, many unhappy families have an admirable spirit dogged
persistence in the face of generations of trials and sorrow. Physicians who appreciate this
fortitude can be very helpful to such families and can derive great satisfaction from
serving as a needed advocate and ally.

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SECTION 03 CONCEPTS OF FAMILY MEDICINE

Role of the Family Physician in Handling Family Dysfunction

An understanding of the family in terms of the its struggles to be functional will enable
the family physician to make more correct diagnoses and also intervene more appropri-
ately. Helping individuals from dysfunctional families to recognise that there are more
healthy ways to respond to the situations of the day is often the start towards a more
functional individual and family.

LEVELS OF PHYSICIAN INVOLVEMENT IN THE FAMILY

There are five levels of physician involvement in the family (Doherty & Baird, 1986):

Level 1. Minimal emphasis on the family. The interaction is limited to the patient only

Level 2. Providing medical information and advice. This consists of teaching at least
one family member about the patient's illness either as a once-off or an ongoing series of
educational sessions.
Level 3. Providing feelings and support. Family support is enhanced by convening the
family members and encouraging them to discuss their concerns. The family physician
must be able to ask questions that elicit family members' expressions of concerns and
feeling related to the patient's condition and its effect on the family. He also needs to be
able to listen emphatically to their concerns and to normalise them where appropriate,
encouraging family members in their efforts to cope as a family and identifying
family dysfunction.

Level 4. Systematic assessment and planned intervention. At this level the family
physician engages the family members, including the reluctant ones in a planned family
conference or a series of conferences. He is also able to help the family generate
alternative, mutually acceptable ways to cope with their difficulty and he is able to help
the family balance their coping efforts by calibrating their various roles in a way that
allows support without sacrificing anyone's autonomy.

Level 5. Family therapy. At this level, the family physician has the ability to handle
intense emotions in families and self and to maintain neutrality in the face of strong
pressure from family members or other professionals.

FAMILY DYNAMICS

Family dynamics may be defined as the interactions and relationships among the
individual members of a family. Family dynamics reflect and influence the physical, mental
and spiritual health of the individuals in a family. An understanding of the dynamics helps
the attending family physician to diagnose the disease and dis-ease in the patient sitting
in his consultation room and to recognise the factors that may help or retard the recovery
of this patient.

60
Assessment of Family Dynamics

Family dynamics may be assessed through its:

• Structure – namely, the genogram.
• Relationship of the members – A child in agreeing to "draw your family" shows the
relationship of each member to one another by the distances separating each other.
Similarly, the nearness of the distances separating members in a family conference tells
us the relationship that each enjoys with the other members of that family.
• Impact on members – collect information of impact of family dynamics using the
acronym of BATHE (see previous chapter).

STRUCTURE – The Genogram

The genogram is a biopsychosocial family tree. It records the family in its life cycle, family
illnesses and relationships.

A genogram can be drawn in skeletal form during one of the first few visits – ideally the
first visit – and then it can be elaborated during subsequent visits as more is known about
the family. See Figure 2 and the table of symbols on how it is done (Table 1).

Figure 2. Drawing the Genogram

Step 1 – Drawing a skeletal genogram
• Indicate the identified patient with a doubly outlined circle or square.
• Represent each family member with a square for male and circle for female and link them up
as in the table of symbols. For the adult patient, the current and past marital partners,
children, parents and grandparents are included. Information about diseased members is
often useful (e.g. age at death and cause of death).
• Place the "clinical nuclear family" roughly in the middle of the diagram, with
previous marriages off to the right and left.
• Place siblings in chronological order, unless they are from multiple marriages.
• Offset index patient, spouse(s), and ancestors a little below their siblings.
• Indicate exact age (if known) inside the person's symbol, with date of birth
alongside, or indicate approximate ages relative to the patient as +4, -3 etc inside
or alongside the circle or square that symbolises the person.
• Indicate death by crossing through the person's symbol: add date died beside,
and age at death inside or alongside the person's symbol.
• Indicate separation with single slash, divorce with two slashes across the
marriage line.
• Number marriages for sponses, with dates of marriage separation, and divorce.
• Indicate remarriage to same person with multiple marriage lines.
• Enclose current household members with an interrupted line (dashes).
• Try to keep members of the same generation on the same horizontal level for
each branch of the family.
• Link the relationship of two persons with lines of conflict or close relationship
as appropriate.
Step 2 – Expanding the genogram
At a later date, enter serious physical and mental health problems for each family member, as they
become known. Specific inquiry is desirable for heart disease, high blood pressure, diabetes,
stroke, cancer, nerve problems, depression, alcoholism, and suicide.

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Table 1 - Standardized Symbols used in Family Genograms

male conflict
female close relationship
sex not specified members of
households
deceased
A adopted female m 3/8/76 married
b date of birth m 3/18/76
d 6/10/79 divorced
m date of marriage
d date of divorce unmarried
relationship
D date of death
abortion or miscarriage
m 9/11/79 m 3/18/76 married husband
m 11/9/84 d 1/3/82 d 5/10/79 with two previous
marriages

m 5/6/72 m 4/4/70
marriage couple marriage
with 3 children with
twin boys
b 10/21/78 b 4/13/80 b 8/1/82
b 9/17/76
oldest youngest

Uses of the genogram. The genogram helps the doctor to:

• Integrate quickly the data on the physical and mental aspects of health and illness in
the family (This information is diachotomized in written histories and notes).
• Graphically displaying multigenerational patterns of illness and dysfunction, for the
clinician to inquire or intervene as time, interest and skills will permit.

Relationship of Members

Draw your family. In children, this may give some idea of the child's perceptive world.
The distant father may be drawn very small or left out altogether. The fierce uncle may be
given some embellishment to state the fact and so on.

Spatial relationship. The spatial distribution of members in a family conference can give
some information on the relationship amongst the family members. Those with better
relationships will sit closer to one another and those not so close will sit further apart.
References
Doherty WJ & Baird MA. Developmental levels in family-centered medical care. Family Medicine 1986;
18:3:153-156.
The Family in Health and Disease in: McWhinney. Chapter 10; A Textbook of Family Medicine, 2nd edition, 1997
pages 229 to 244.

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CHAPTER 4 EMERGENCY CARE AND
HOUSE CALLS

Outline
Emergency care
House calls

EMERGENCY CARE

An emergency is an unforeseen occurrence or a combination of circumstances calling for

immediate action or remedy.

Scope of Emergency Care seen in General Practice:

Paediatric emergencies - E.g.: persistent crying, fever, vomiting, diarrhoea and abdominal
pain, childhood injuries, fits, foreign bodies, accidental poisoning, and epistaxis.

Cardiovascular emergencies - E.g. chest pain, acute left ventricular failure.

Respiratory emergencies - Mainly acute breathlessness secondary to asthma, pneu-

mothorax, hyperventilation; acute laryngeal obstruction caused by foreign bodies or
angioedema. Haemoptysis occasionally.

Gastrointestinal emergencies - Abdominal pain and food poisoning, haemetemesis,

melena, rectal bleeding, etc.

Urogenital emergencies - Acute urinary retention, renal colic, acute testicular pain, etc.

Obstetric and gynaecological emergencies - Pregnancy-related conditions e.g. an-

tepartum haemorrhage, ectopic pregnancy. Gynaecological conditions e.g. twisted
ovarian cyst, pelvic inflammatory disease with severe lower abdominal pain. Breast
engorgement and haemorrhage in the pueperium occasionally.

Neuromuscular emergencies - E.g. stroke, transient ischaemic attack, oculogyric crisis,

loss of consciousness, head injury, skeletal injuries.

ENT and eye emergencies - Foreign bodies; severe pain as in glaucoma, earache, a
particularly painful sore throat which may be perceived by the patient as an emergency;
vertigo; epistaxis; sudden loss of vision; physical and chemical injuries. Dental problems
such as bleeding after extraction occasionally.

Endocrine emergencies - Not common. E.g. diabetic ketoacidosis and hypogly-

caemic coma.

Bites and stings, burns and scalds - Bee and wasp stings most common. Animal bites
such as by dogs, snakes and even fish, depending on the location of practice. Burns and
scalds common.

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