Introduction to Family Medicine

Family medicine:
Is a primary care oriented clinical specialty with his own specific educational content,
research, and base of evidence. It is a broad specialty that integrates the biological,
clinical, and behavioral sciences. It provides continuing and comprehensive health care
for individuals and families The scope of family medicine encompasses all ages, sexes,
organ systems, and disease entities.

Family physician:
- Is a specialist trained to work in the front line of health care system and to take initial
steps to provide care for any health problem that patient may have.
- At present, family physicians complete a 3-year residency in family practice. This
prepares them to manage the broad scope of problems (biological, social and
psychological) involving patients, from newborns to the elderly. The family physician
typically provides a broad range of services, including acute and chronic disease
management in the office, hospital, or home, or by telephone.
- The family physician is often the patient’s first contact and is available if the patient
has an urgent or chronic problem.

5Cs of family physician

1) Comprehensiveness of care:
A spectrum of care that covers a broad range of patient’ needs . Comprehensiveness as it
applies to the provider ability to competency manage problem that are common in the
community. It Provides broad range of services including acute and chronic diseases
management, prevention and psychological management, Care in clinic, hospital and
home or via telephone.

Indications for home visits

- When the patient is elderly (geriatric evaluation), or disabled, or newborn in the
family.
- Family physician concerned about safety of home environment.
- Family physician concerned about quality of care from family members at home.
2) Continuity of care:
Family physicians typically develop a trusting long-term relationship between patient
and physician, maintain longitudinal records of patients’ problems, and promote healthy
lifestyles.
Continuity of care from patient’s point of view: the degree to which each interaction
with the health care system over a period of time occurs with the same provider often
described as "cradle to grave" ‫اﻟﻠﺤﺪ اﻟﻰ اﻟﻤﮭﺪ ﻣﻦ‬

Follow patients over time

Follow patients in different settings
Experience relationship and responsibility of care
it is a valuable tool for improving patient adherence to treatment

Four dimensions of Continuity of care:

1. Provider continuity: is defined as the degree to which a given patient sees the same
provider whenever he accesses a care
2. Informational continuity: is defined as the degree to which any provider seeing a
patient has access to complete information about the patient’s previous illnesses and
encounters with the health care system
3. Chronologic continuity can exist over time between a doctor and a patient
(longitudinal care)
4. Geographical continuity: implies that the provider care for the patient regardless of
where the care is provided

Benefits of continuity of care:

It improves patient satisfaction with health care
It improve physician satisfaction and quality of care

3) Coordinated care:
It refers to the organization of health care services in order to meet the needs of the
patient. A key element of this is the referral of the patient to a specialist. Although
approximately 95% of patient problems seen in the outpatient family practice setting can
be handled by a family physician (aware of pt. entire list of problems), 5% will need specialist
attention. Appropriate management with appropriate resources or sector.

4) Compassionate:
Partnership, friendship with patient mutual respect .empathy and sympathy
5) Competent:
The general categories of competencies (skills) for the practice of family medicine:
Communication and interpersonal skills
Cultural competency
Prevention care competency
Competency to continuously educates oneself
Competency to assess community needs
Competency to care for acute, chronic and behavioral problems that are common in the
community
Competency to recognize uncommon problem
Competency to organize and coordinate the health care team
Proper apply of knowledge &skills to solve problems and Approach to the health care is
based on the best scientific evidence available EBM

Advantage of family medicine system:

- For the doctor Training and continuing medical Education Vocational stability
Favorable (environment) climate for work Improve the income Acquire new skills
- For Government
Reduce the cost (economic feasibility) No duplication of service ( drug abuse) without
medical reasons. Reduce the number of required tests and repeated Reduce the number of
admissions in the hospital. Increase health awareness in the community.
- For Community get good service.
Improve the health level (physically, psychologically and socially).
Increase productivity
Improve the quality of life that. Achieve comprehensive development and sustainable

Role Family physician

1. MANAGERIAL ROLE
a) Training
b) Community diagnosis (survey)
c) Inter-sectoral coordination
d) Accuracy of reports.
e) Accuracy of implementation of national policies and strategies.
2. PREVENTIVE ROLE
a) Health education
b) Environmental sanitation
c) Immunization
d) Initiation , utilization, integrity of family health records
e) Providing primary health care
f) Establishing well baby clinic
g) Identifying at risk groups
h) Early diagnosis & appropriate management

3. CURATIVE ROLE
a) Treatment of common health problems
b) Deal with emergencies
c) Referral to secondary level
d) Continuous management of chronic illnesses
e) Home visits (OUTREACH PROGRAMS)
 Family health record

One of the most important tools used by family physicians in their practice are medical records
and registers. They play essential roles in providing high quality health services in
family practice.
Important uses of medical records
Providing data base for individuals and families.
Help in providing continuity care. Used for on-going continuous care.
Help in auditing the health services.
Help in vital statistics and decision making.
Used as documents for legal aspects and investigations if needed (medico-legal aspect of care).
Help in communicating the relevant facts concerning the patients care among the health team.

Criteria of good medical records:

They are organized in logical and systematic manner.
They are complete.
They are simple and accurate.
They reflect the status of health and illness of the individuals and of the communities.
They could be retrieved quickly

Contents of medical records

Family Health file
Family Health Record (FHR) is a cumulative record (folder) of all family members.
It gives data base about house of the family concerning:
Type of house.
Source of water, sanitation, lighting, ventilation.
Number of rooms, bath, kitchen... etc.
Presence and of absence of insect, rats.
General health condition of the house.
It contains the individual medical file of each member of the family providing with all data
base.

- Individual medical file: consists of the following sheets:

Data Base Sheet:
Contains (Date of birth, sex, marital status, educational status, occupation, medical, surgical,
family, social history, drug history, history of allergies).
Physical Examination Sheet:
Includes initial clinical examination such as weight, height, BMI, eye, ear, nervous system,
cardiovascular system, respiratory system, gastrointestinal system, musculoskeletal system.

- Lab Sheet:
Include base line investigations such as urine, stool, blood and electrolyte follow-up Sheets:
They consist of many pages specified for follow-up visits. they contain space for date, vital
signs, complaints and clinical findings, diagnosis, treatment and appointment.
List include:
- Pathological diagnosis (Thyroditis).
- Disability (Deafness).
- Deformity (Scoliosis).
- Social (Poverty).
- Psychological (Stress).
- Clinical diagnosis (Hypertension).
- Chronic symptom (Fatigue).
- Active health problem (Bronchial Asthma).
- Inactive problem (Old Tuberculosis).

Progress Note:
• Progress note is designed to record the progress of the patient either for one or multiple
problems in family practice. We usually use progress note depending on (SOAP System).
• SOAP System stands for: Subjective, Objective, Assessment and Plan.
• For each problem, all these four elements should be covered adequately
Example:

- 45 years old male presented with cough for tachypnea and chest X-rays showed left lung co
progress note of this patient as follows:
` Subjective: What is the patient complaint? (cough).
` Objective: What is your clinical and lab. findings? (tachypnea and left lung collapse)
Assessment: severely distressed patient due to left lung collapse (diagnosis and clinical status of
the ease).
` Plan: What should be done? Immediate referral to chest physician.
` S: Cough for 3 days,
` O: left lung collapse.
` A: Severe distress due to collapse of left lung
` P: Immediate referral to chest physician.

Flow sheets:

- the How sheet is a special sheet designed in relation to time. It is useful to find out the
changes which occurred in a patient during the short time. It has the following advantages:
- Quick data retrieval.
- Easy comparison of date.
- Easy reminder to the health professionals.

flow sheet is usually used to assess changes in parameters such as:

- Blood pressure in hypertensive patients.
- Blood sugar in diabetics
- Input/output of urine in patient w ith acute renal failure.
- Peak flow Meter in asthmatic patients.

Special Lists:
^ In family practice we use some special lists which are considered advantageous for patient and
physician. These lists could be used to remind the physician or can be used for auditing. These
lists include:
^ Drug list (deals with the recording of all the drugs used by the patient (name, dose, frequency,
duration and route of administration).
^ Health education list (deals with the title of the topics which were discussed w ith patient such
as diabetic, asthmatics and obese patients).

Special Forms:
In family practice we use special forms for special patient. These forms could be part of the
patient's file. These forms are designed for special purposes.
- for example: Diabetic form which consists of many sheets: the fist one designed for data
base, the second page for follow-up visit, third page for annual check-up, fourth page for
health education and the fifth page for drug list.
Similar forms could be used for hypertensive, asthmatic and obese patients.

Special Registers:

* In family medicine and primary health care practice, we have many registers. These registers
include:
- Birth register.
- Death register.
- Drugs register.
- Communicable disease register.
- Morbidity register.
- Outpatient clinic register.
- Immunization register.
- Antenatal care register.
- Health Education register.
-Laboratory register.
- High risk baby register.
- Dressing and injection register.
- Emergency department register.
- Reproductive age register (female age 15-45 years).
- Referral register.

Methods of storage medical records:

Medical records can be stored or retrieved by using many methods. However, the most common
two methods are:
• Alphabetic filing system:
In this system the records are stored according to surnames of individuals. One of the common
problems of this system is misfiling due to similarity of many names and ethnic group.

• Numeric System: This system is commonly used in Medical Record Department, and
accurate.
 Referral

Referral System Definition

Is the process in which the family physician at the family health center who has
inadequate skills due to his qualification and/ or lesser facilities at his level to manage
a clinical condition. He seeks the assistance of a better equipped and qualified
specialist, with better resources at the higher level to guide him in managing a clinical
condition.
Referral does not mean transferring responsibility; it is sharing responsibility in
patient care

When to refer? Reasons for Referrals

1.When the family physician need specified investigation or advice on his
management
2.When the family physician is dissatisfied with the patient’s progress or unsure of
the diagnosis (uncertainty)
3.When the patient or his family shows doubt or lack of confidence in the diagnosis
or management
4. Medical-legal cases

Factors affecting referrals

- Availability of qualified consultants
- Physician specialty
- Length of training,
- Unexplained findings
- Uncertainty of diagnosis
- Patient characteristics

The referral process

• The decision is made
• Consideration is given to the patient’s medical, emotional, cultural and
socioeconomic background.
• Selection of appropriate specialty and appropriate physician in the field
• Preparation for both the patient and the family for consultation
• Preparation of the consultant
• The consultant provides feedback to the family physician The family physician
evaluates the appropriateness of the consultant’s recommendation
• The family physician facilitates the patient and the family’s acceptance of recommendation
• The family physician acts on the recommendations or selects another consultant in
the same or different field
• The family physician provides feedback to the consultant regarding the outcome
Referral letter outline
1.Patient details(name, location, age and sex).
2.Details of family physician (name of physician making request and Name of
physician being consulted)
3.Reasons for referral
4.Degree of urgency for appointment
5.Clinical problem
6.Important Previous history
7.Findings on physical examination
8.Findings on investigation (photocopies of results should be included)
9.Medication and drug sensitivities
10.Expected outcome and Desirable follow up.

Types of referrals
^ Emergency referral
To reach the expert hand in a proper time and better condition without deterioration
and providing all expected information in referral litter writing.

^ Opportunistic referral.
Refer For :
-Expert opinion
-Admission
-Investigations
-managements

Modern classification:
1- Interval: e.g: patient with MI admitted in hospital for a period of time then return
for continuity of care.
2-Collateral e.g: diabetic patient with glaucoma to ophthalmologist.
3- Cross referral which is self referral.
4- Spilt referral as in multi-specialty in the same center.

Disadvantages of self-referral and direct access to hospital:

1.inefficient care.
2. Increase waiting time.
3.lack of continuity and follow -up.
4. loosing way between different hospital sections.
5.wastage of resources at all level
Levels of Referral
a. First level: From family physician primary health care to hospital specialist.
b. Second level: From specialist to another specialist.
c. Third level: from junior specialist to senior specialist.
d. Fourth level: from general hospital to specialized hospital.

Importance of Referral
For the patient
-Prompt diagnosis and management -Save time, money and effort.
-Better outcome
For the family physician -learning and training -Gaining self confidence.
-Increase communication between the health care staff
For the Consultant
-Improve the quality of the patient's management. -Increase communication between
the health care staff
 Counselling

Counselling Definition:
Is the act of helping the counselee (patient) to make her or his own free informed
decision, through the help and support of the counselor (health care provider), with no
pressure for leading to a decision, avoid giving advise

Aim:
Help the patient to make his own decision
Counselor act as a facilitator

Types of counselling
• Individual counseling
• Group counseling

Counselling setting
- Setting: quiet, calm
- Timing: 45-60 min
- Interpersonal space: 90 degree angle

Difference Between Counselling and Health Educator

Counseling Health education

No advice Advice
Individual(usually) or group Group (usually)
Health care provider Not necessary health care provider

Role of family physician (counselor) in counselling

• Family physician should:
1. Help the counselee (the patient) to identify what is the problem,
2. Help the counselee to discover why it is a problem
3. Encourage the counselee to look at possible solutions
4. Help the counselee to take personal decisions and choose the appropriate solution
5. avoid advising the counselee
 During counselling:
the counselor should:
Q. good counselor or skills of counseling
1. Give clear correct information
2. uses short sentences and easy words
3. Use client's language
4. Use promotional material & samples
5. Repeat the instructions
6. Ask the client if has understood, encourage him to ask
7. Ask client to repeat instructions
8. Good communication
•Active listening verbal, non verbal: Observation of non verbal messages, inner feelings
(eye contact, facial expression, posture, body movements, posture
•Using the same language of the client.
9. Keeping appointments
10. Being on time.
11. Confidentiality.

Types of Questions during counselling

1.Open ended questions (Preferred)
2.Clarifying when part is poorly understood
3.Restatement: to overcome generalization
4.Paraphrasing and summarizing: reorganize the essential part of the message into
concise statement.

Tools of effective communication during counselling

1.Communication skills.
2. Technical information.
3. Understanding the stages of the counseling process

BARRIERS TO COUNSELLING
1. Language
2. Gender
3. Literacy
4. Education
5. Socio-economic status
6. Sitting while the client stands or sitting far away from client
Approach of counselling GATHER Approach
G – Greeting the client kindly
Introduce yourself to client
Address client by name
A– Ask the client (to gather information)
Q– simple questions – good communication
T –Telling the client about all information related to counseling topic
H–Help the client to choose or make the decision
E–Explain to the client (how to implement his or her decision.
R– Return visit and emergency visit

Fields of counselling (Examples):

• Premarital and sexual education
• Genetic counseling
• Breast feeding counseling
• Family planning
• Counseling to prevent Tobacco use
• Counseling to promote physical activity
• Counseling to promote a healthy Diet
• Counseling to prevent Motor-Vehicle injuries
• Counseling to prevent low back pain
• Counseling to prevent Dental diseases
• Counseling to prevent cancers
• Counseling to prevent SIDS
• Counseling to prevent STD
• Counseling to promote breast feeding
• Counseling for stress
 Adherence

Definition of adherence:
- Adherence to (or compliance with) a medication regimen is generally
defined as the extent to which patients take medications as prescribed by
their health care providers.
- The word "adherence" is preferred by many health care providers, because
"compliance" suggests that the patient is passively following the doctor's
orders and that the treatment plan is not based on a therapeutic alliance or
contract established between the patient and the physician

• White Coat adherence:

Is defined as Patients improve their medication-taking behavior shortly before and
after an appointment with a healthcare provider

Effects of poor adherence:

- Poor adherence result in treatment failure, increase cost benefit ratio.

- Increase use of medical resources eg; more visits for physician and
emergency department more hospital admission, nearly 10 – 33% of elderly
admitted had a history of non adherence,
- poor adherence also results in increase nursing home visits, unnecessary
additional treatment and additional laboratory testing

Factors affecting adherence:

Patient
factors

Socio Health care

economic
related Drugs
factors Factors
Factors

Disease
Factors
• Physician patient relationship:
A good relationship between the patient and health care provider, which features
encouragement and reinforcement from the provider, has a positive impact on
adherence

Disease related factors:

- Condition-related factors represent particular illness-related demands faced
by the patient and the cultural meaning of the illness.
- Factors related to the symptoms experienced by the patient, level of
disability (physical, psychological, social and vocational), severity of
disease, rate of progress of the disease and the availability of effective
treatments are strong determinants of adherence.
- Their impact comes from the manner in which they influence how the
patient perceives risk, the importance of following treatment, and the
priority placed on adherence. Also, some co morbidities, such as depression,
are important modifiers of adherent behaviors

Therapy related factors:

There are many therapy-related factors affecting adherence. Important ones are
those related to the access to medications, the complexity of the therapy the
immediacy of beneficial effects, side-effects(SE) and the availability of medical
support to deal with them.

Patient-related factors:
Patient-related factors represent the resources, knowledge, attitudes, beliefs,
perceptions and expectancies of the patient, for get fullness

Socio Demographic Factors:

It plays only a small part

How to improve adherence?

^ Patient-related factors:
Cognitive therapy
Education about the illness
Education about the treatment
Memory aids (phone reminders, alarms)
Involvement in therapeutic alliance
~ As regard provider communication it is very important to:

- Adopt a friendly rather than a business-like attitude

- Spend some time conversing about nonmedical topics
- Avoid medical jargon
- Use short words and short sentences
- Give clear instructions on the exact treatment regimen, preferably in writing
- Repeat instructions
- Make advice as specific and detailed as possible
- Ask the patient to repeat what has to be done

^ Social and environmental related:

- Involve and educate family
- Improve access to mental health services (case management, home visits,
convenient clinic hours and locations)
- More attractive clinic environment
- Improved coordination among service providers

^Treatment related:
o Minimize complexity of medication regimen
o Titration to optimum dose
o Provide clear instructions on medication use
o Minimize impact of side effects
o Select medication with fewer side effects

How to measure adherence:

§ Direct methods
Measurement of drug/metabolite levels
§ Indirect methods
Pill counts
Self-reported (questionnaires, visual analogue scales)
Electronic databases