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Holistic Diagnosis and

Comprehensive Management

Dr. Oryzati Hilman Agrimon, MSc.CMFM, PhD (C)


PhD Candidate in General Practice/ Family Medicine,
the University of Adelaide, Australia
Lecturer
Department of Public Health and Family Medicine
Faculty of Medicine and Health Sciences
Universitas Muhammadiyah Yogyakarta

Discussion Topics
The Role of Family Doctor
Level of Physician Involvement in the Family
The Application of Holistic Approach in the
Management of Patient

The Five-Star Doctor


Peran Five-star Doctor (WHO, 2000) dalam
suatu sistem kesehatan yg merespon kebutuhan
masyarakat:
Health
care
provider

Decision
maker

Manager

FIVE-STAR
DOCTOR
Community
leader

Communicator

Modifikasi Five-star Doctor menjadi


Five-star Family Doctor oleh Philippine
Academy of Family Physicians (PAFP, 2001)
Bio-medicalclinical science

Health
care
provider
Health
Organization & Administrator/
Management
Manager

CME & CPD, IT


EBM & Research

Life-long
learner/
researcher

FIVE-STAR
FAMILY
DOCTOR

Counselor/ Communication &


Advocate Counseling Skills

Health
educator

Health Promotion,
Disease Prevention &
Life-style modification

Levels of Physician Involvement in the Family


Five Levels of Physician Involvement (LPI) in the
Family (Tingkat Keterlibatan Dokter dalam
Keluarga): (Doherty & Baird, 1986 in Goh et al
2004, McDaniel et al 2005, Sloan et al, 2002)
Level 1: Minimal emphasis on the family

(Penekanan yang minimal pada keluarga)

Level 2: Providing medical information & advice


(Memberikan informasi & nasihat medis)

Level 3: Providing feelings and support


(Memberikan perhatian pd perasaan & dukungan)

Level 4: Family assessment & counseling


(Penilaian keluarga & konseling)

Level 5: Family Therapy


(Terapi keluarga)

Patient

Family

Physician
(Doherty & Baird, 1980)

Notes:
Family-centered FD thinks family in every 10-15
encounter with a patient
Most non-family-oriented physicians operate at level 1
Most FDs move between levels 2 and 4 at any given
time
FDs who pay attention to the family save time, energy &
money & yield favorable results for the physician & the
patient
To provide quality health care, family-oriented physicians
use the most basic resources available to them: the
patient & his/her family
the family is the natural partner in health care
The therapeutic triangle in medicine: involves the
clinician, the patient & the family working together in a
medical-care partnership

Level 1: Minimal emphasis on the family


The interaction is limited to the patient only
The doctor-centered encounter: one way communication
The physician focuses on gathering biomedical & family
information needed to make the correct diagnosis & treatment

Level 2: Providing medical information & advice


The family is a partner in care
Collaborative information exchange
The physician communicates information clearly to patients &
families: teaching at least 1 family member about the
patients illness
The physician solicits patient & family input into diagnostic &
treatment planning

Level 3: Providing feelings & support


FD goes beyond the problem to actively address emotional
issues of the individual patient & the family
FD demonstrates emphatic listening and elicits expressions
of feelings & concerns related to the patients conditions & its
effect on the family
FD normalizes feelings & emotional reactions to illness,
encouraging family members in their efforts to cope as a
family & identifying family dysfunction

Level 4: Family assessment & counseling


FD assesses the relationship between the illness problem
and the family dynamics
FD seeks to work to catalyze change in psychosocial health
through encounters with the patient and/ or the family
Brief counseling: may occur over 1 or several visits; common
in practice & can be extremely effective; involves identifying
problems & potential solutions;
If the problem is not complex & long-standing, work with
family to achieve change
If the problem is entrenched or family counseling is not
effective, make a referral to family therapist

Level 5: Family therapy


FD meets with the patient & the family regularly for multiple
sessions to change unhealthy patterns within the family
system
Medical family therapy is intensive specialty care delivered by
professionals with advanced psychotherapy training

Application of Holistic Approach


in the Management of Patient
Perumusan masalah dan penyelesaian masalah
kesehatan tidak didekati dari satu aspek saja
Holistic
History
Taking

Bio-psycho-social
model

Holistic
Diagnosis

Holistic
Management

A Case with 2 Scenarios


A 45-year-old insurance broker who is under
a lot of work stress recently because his
company management has set some new
business targets that he has difficulty in
meeting. He is not sleeping well at night an
feels rather tired in the day. He starts to
think that he cannot cope with his work
because his health is ailing. He looks for
signals of illnesses from his body and he
noticed that he has some belching. So he
goes to see a doctor..

A: What happens if???


If he consults a gastroenterologist first, he
will most likely be subject to an upper GI
endoscopy and H-pylory testing, which most
likely to be negative. The gastroenterologist
will reassure him that there is nothing wrong
with him and prescribe some empirical
symptomatic treatment. He still feels tired
and starts to look for other symptoms, shop
for doctors and undergo further
investigations to find out what is wrong with
him.

B: What happens if???


If he consults a family doctor first, he will
be evaluated on not only his belching but also
his underlying concerns, psychological state
and social situation. The family doctor will be
able to detect his work stress in addition to
his presenting symptom. Apart from deciding
on whether further investigation and drug
treatments for the belching are needed, the
family doctor will also look for any
psychological disease and offer counseling to
his stress. After seeing the family doctor,
he will try to solve his problem by stress
management instead of using the health
service.

Exploring both the


Disease & illness
experience

Understanding
the whole
person

Finding
Common
ground

Physical, history, lab

Disease
Patient
Presents
cues

CONTEXT

PROBLEMS

PERSON
Illness

Illness

Mutual
Decision

Disease

Ideas, expectations
Feelings, effect on
functions

Enhancing
Patient-doctor
relationship

GOALS

ROLES

Incorporating
Prevention and
Health promotion

Being realistic

The Patient Centered Clinical Method

Culture
Community

The Mandala of Health:


A model of human
ecosystem

lifestyle
Personal
behavior
Sick
care
system

spirit

body

Human
biology

Psycho-socioEconomic
Environment

work

mind

Physical
environment

Human-Made Environment
Biosphere

Holistic History Taking:

- History of patient, including Personal Social History:


education, work, family, marriage, lifestyle
- Exploring both disease & illness
- Identification of risk factors
- Psycho-social analysis of family dynamics:
using family assessment tools

Holistic diagnosis (bio-psycho-social analysis)


- Medical diagnosis
- Psycho-social diagnosis: result of psycho-social
analysis of family dynamics

Holistic intervention:

- Level of physician involvement in the family (LPI):level 2-4


- Medical intervention based on EBM
- Psycho-social intervention: individual & family
counseling (not only giving advice)
- Preventive measures

Algoritme Manajemen Pasien dengan


Pendekatan Holistik

History of
Patient:
Personal
social
history
Disease &
illness
Risk
factors
Impact
of
Illness

Genogram

Patient

Family Map

Holistic
History
Taking

Family
assessment
tools

Physical
Exam

Investigations
Medical
Diagnosis
Medical
Intervention
Based on EBM

Preventive Measures

Holistic
Diagnosis
Comprehensive
Management

Psychosocial
Diagnosis
LPI: level 2-4
Psychosocial
Intervention

Family
Life Cycle
Family
Life Line
Family
APGAR
Family
SCREEM

Contoh diagnosis yg holistik:


OMSK berisiko lanjut pada balita dengan
kurangnya kepedulian keluarga
Dampak bio-psiko-sosial HIV/AIDS pada pasien &
keluarganya
Pengaruh faktor genetik, sikap & perilaku serta
dukungan pasangan thd keberhasilan pengobatan
TBC & DM pada kepala keluarga
Asma bronchiale tidak dalam serangan &
hipertensi terkontrol pada kepala keluarga dg
faktor risiko tempat tinggal & masalah psikososial
PPOK pada kepala keluarga yang tidak bekerja
dengan perilaku merokok yang kontinyu
Hipertensi pada istri sebagai pencari nafkah
utama keluarga terkait dengan stressor psikis

Diagnosis Holistik
PPOK Derajat Ringan Eksaserbasi Akut pada LakiLaki Paruh Baya Tidak Menikah, Mantan Perokok
Sedang dengan Status Ekonomi Rendah dengan
Ketidaktahuan dan Kekhawatiran terhadap
Penyakitnya dengan Fungsi Keluarga yang Kurang
Sehat pada Rumah Tangga yang Tidak berperilaku
Hidup Sehat
Manajemen Komprehensif:
* Promotif =
* Preventif =
* Kuratif =
* Rehabilitatif =

Learning Points...???

Thank you for your attention!


Questions are most welcome!

Wassalamu alaikum Wr.Wb