Introduction: Family Medicine

Cynthia Lazaro-Hipol, MD,MPH,FPAFP

Family Medicine
y medical specialty y continuing and comprehensive health

care for the individual and family. y integrates the biological, clinical, and behavioral sciences. y encompasses all ages, both sexes, each organ system, and every disease entity.

Family medicine is a threedimensional specialty (1) knowledge, (2) skill and (3) Process
patient-physician relationship with the patient viewed in the context of the family relationship is valued, developed, nurtured and maintained

Basic Principles of Patient Care in Family Practice

yPatient - Centered yComprehensive Care yContinuity of care yContext of Care yCoordination of care

Biopsychosocial Model (PatientCentered)

y approach patients with sensitivity and

responsiveness to culture, age, gender, and disabilities y develops their ability to collect and incorporate appropriate psychosocial, cultural, and family data into patientcentered management plans
(Annals of Family Medicine Supplement, March 2004).

Comprehensive Care (Whole Person Care)

y emphasizes the importance of caring for

the whole person by providing opportunities for students to participate y in longitudinal, integrated, preventive services and treatment of common acute and chronic medical problems for patients and families in all phases of the life cycle.
(Annals of Family Medicine Supplement, March 2004).

Continuity of Care (Continuous Healing Relationships)

y values and promotes continuous healing

relationships by y providing a personal medical home for patients and their families y maintaining ongoing responsibility for the health care of patients and families y facilitating transitions between the primary care provider, referral agencies, and consultants.
(Annals of Family Medicine Supplement, March 2004).

Context of Care (Evidence-Based)

y emphasizes the development of patient-

and family-centered treatment plans y evidence-based, safe, and designed to produce high-quality outcomes that enhance functional outcome and quality of life in a culturally responsive manner
(Annals of Family Medicine Supplement, March 2004).

Coordination / Complexity of Care (Integration)

y functions as the integrator of

complex care and collaborates as a health care team member in disease management, health promotion, and patient education.
(Annals of Family Medicine Supplement, March 2004).

Attribute

Description

A deep consider all the influences understanding of on a person s health. the dynamics of integrate rather than the whole person fragment care, involving

people in the prevention of illness and the care of their problems, diseases, and injuries

Attribute

Description

A generative impact on participate in the birth, growth, patients and death of their patients and lives

want to make a difference in their lives.

family physicians foster personal growth in individuals and help with behavior change that may lead to better health and a greater sense of well-being

Attribute Description
A talent for humanizing the health care experience

intimate relationships over time enable family physicians to connect with people. explain complex medical issues in ways that their patients can understand. take into account the culture and values of their patients, while helping them get the best care possible

Attribute
A natural command of complexity

Description

comfortable with uncertainty and complexity. trained to be inclusive, to consider all the factors that lead to health and well-beingnot just pills and procedures

A commitment to not only physically accessible to multidimensional patients and their families and accessibility

friends, able to maintain open, honest and sharing communications with all who are involved in the care process

Roles of a Family Physician??

y Educator/ Health Advocate y Researcher y Manager y Community Organizer y Care-giver

cancer patients should expect to receive

y competent general medical care, advice

regarding y treatment, care coordination, pain management, and y end-of-life care and emotional support from their primary care physicians.

Characteristics of the New Model of Family Medicine

Patient-centered care
y Patients are active participants in their

health and health care. y The practice has a patient-centered, relationship-oriented culture that emphasizes the importance of meeting patients needs, reaffirming that the fundamental basis for health care is "people taking care of people"65

Characteristics of the New Model of Family Medicine

Personal medical home yThe practice serves as a personal medical home for each patient, ensuring access to comprehensive, integrated care through an ongoing relationship

Characteristics of the New Model of Family Medicine

Team approach
y health care is not delivered by an

individual, but rather by a

y multidisciplinary team approach for

delivering and continually improving care for an identified population41,67

Characteristics of the New Model of Family Medicine

Elimination of barriers to access

y through implementation of open

scheduling, expanded office hours, and additional, convenient options for communication between patients and practice staff

Characteristics of the New Model of Family Medicine Advanced information systems

y use an information system to deliver and

improve care, to provide effective practice administration, to communicate with patients, to network with other practices, and to monitor the health of the community.68 y A standardized electronic health record (EHR), adapted to the specific needs of family physicians, constitutes the central nervous system of the practice

Characteristics of the New Model of Family Medicine

Redesigned offices
y Offices should be redesigned to

meet changing patient needs and expectations, to accommodate innovative work processes, and to ensure convenience, comfort, and efficiency for patients and clinicians

Characteristics of the New Model of Family Medicine Whole-person orientation

y integrated, whole-person care y developing cooperative alliances with services

or organizations that extend beyond the practice setting, but which are essential for meeting the complete range of needs for a given patient population.38 y The practice has the ability to help guide a patient through the health care system by integrating carenot simply coordinating it

Characteristics of the New Model of Family Medicine

Care provided within a community context

y A culturally sensitive, community-

oriented, population-perspective focus

Characteristics of the New Model of Family Medicine

Emphasis on quality and safety

y Systems are in place for the

ongoing assessment of performance and outcomes and for implementation of appropriate changes to enhance quality and safety

Characteristics of the New Model of Family Medicine

Commitment to provide family medicines basket of services

y A commitment to provide patients with
family medicines full basket of serviceseither directly or indirectly through established relationships with other clinicians

Basket of Services in the New Model of Family Medicine

y Health care provided to children

and adults y Integration of personal health care (coordinate and facilitate care) y Health assessment (evaluate health and risk status) y Disease prevention (early detection of asymptomatic disease)

Basket of Services in the New Model of Family Medicine

y Health promotion (primary

prevention and health behavior/lifestyle modification) y Patient education and support for self-care y Diagnosis and management of acute injuries and illnesses y Diagnosis and management of chronic diseases

Basket of Services in the New Model of Family Medicine

y Supportive care, including end-of-life care y Maternity care; hospital care y Primary mental health care y Consultation and referral services as

necessary y Advocacy for the patient within the health care system
y Quality improvement and practice-based

research

Traditional Model Systems often disrupt the patient-physician relationship Care is provided to both sexes and all ages; includes all stages of the individual and family life cycles in continuous, healing relationships Physician is center stage Unnecessary barriers to access by patients Care is mostly reactive Care is often fragmented

New Model of Practice Systems support continuous healing relationships Care is provided to both sexes and all ages; includes all stages of the individual and family life cycles in continuous, healing relationships Patient is center stage Open access by patients Care is both responsive and prospective Care is integrated

Traditional Model Paper medical record Unpredictable package of services is offered

New Model of Practice Electronic health record Commitment to providing directly and/or coordinating a defined basket of services Individual patient oriented Individual and community oriented Communication with practice is Communication with the synchronous (in person or by practice is both synchronous and asynchronous (e-mail, telephone) Web portal, voice mail) Quality and safety of care are Processes are in place for assumed ongoing measurement and improvement of quality and safety

Traditional Model

New Model of Practice

Physician is the main source of care Individual physicianpatient visits

Multidisciplinary team is the source of care 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

A family Physician
MD
2000

Residency Training

CME

Certified Family Physician Diplomate Examination Felow

A family

physician is

y A doctor who graduated in the

1960s; went back to his hometown; see patients of all ages and with varied diseases??????

Jose dela Cruz, MD

False

Physician- Surgeon

family physician is

yA doctor who graduated

three years ago ; passed the board; went back to his hometown and is presently treating patients of all False ages????????????

family physician is

y A doctor who graduated 10

years ago; Completed a residency training in Pediatrics; Passed the Diplomate Board; Sees patients of all ages and False with varied diseases????????? True

A family

physician is

y A doctor who graduated in the 1970s,

went back to his hometown and practice. Attended CME activities of the Philippine Academy of Family Physician in the 1980 s. Got a certificate as a Certified Family Physician.
Jose dela Cruz, MD

Physician- Surgeon True False ?????????????

A family

physician is

y A doctor who graduated in 1975; earned

a Masters degree in Public Health;went back to his hometown and practice; see patients of all ages and varied diseases?

False False

A family

physician is

y A doctor who graduated in 1985;

Underwent three years training in Family Medicine; did not take any diplomate exam; went back to his hometown and practice.? True

False

A family

physician is

y A doctor who graduated in 1085;

Finished a residency training in Family Medicine; Passed the diplomate exam; earned a Masters degree in Public Health.went back to his hometown and practice.? True
True

A family

physician is

y A doctor who graduated in the

1970s, went back to his hometown and practice. Attended CME activities of the Philippine Academy of Family Physician in the 1980 s. Got a certificate as a Certified Family Physician.Passed the diplomate exam. See patients of True all True ages and with different complaints.

y For nos 6 and 9, refer to the case below: y Dr. Gloria Grajera is a 60 year old private practitioner. She

had her residency training in Family Medicine. She has now a MD, FPAFP after her name. She admitted a patient suffering from uncomplicated Myocardial Infarction 2 days ago. She referred the patient to her friend, an internist yesterday for she noted some irregularities in her pulse. Dr. Grajera ordered the dietician to give her patient soft diet for the next three to five days. Likewise she advised the patient not to mobilize or move around because it would cause more harm to the patients heart. y Dr. Grajera is a:
y Internist y Family Physician y Specialist y B and C y A,B,C

y For nos 6 and 9, refer to the case below: y Dr. Gloria Grajera is a 60 year old private practitioner. She

had her residency training in Family Medicine. She has now a MD, FPAFP after her name. She admitted a patient suffering from uncomplicated Myocardial Infarction 2 days ago. She referred the patient to her friend, an internist yesterday for she noted some irregularities in her pulse. Dr. Grajera ordered the dietician to give her patient soft diet for the next three to five days. Likewise she advised the patient not to mobilize or move around because it would cause more harm to the patients heart. y The role/s performed by the above physician:
y Caregiver y Researcher y Manager y Educator y Combination of the above

y Dr. Gloria Grajera is a 60 year old private

practitioner. She had her residency training in Family Medicine. She has now a MD, FPAFP after her name. She admitted a patient suffering from uncomplicated Myocardial Infarction 2 days ago. She referred the patient to her friend, an internist yesterday for she noted some irregularities in her pulse. Dr. Grajera ordered the dietician to give her patient soft diet for the next three to five days. Likewise she advised the patient not to mobilize or move around because it would cause more harm to the patients heart. y Most likely, Dr. Grajera is practicing in a
y y y y

Primary Care hospital Secondary Care Hospital Tertiary Care Hospital Only B or C

y Dr. Gloria Grajera is a 60 year old private

practitioner. She had her residency training in Family Medicine. She has now a MD, FPAFP after her name. She admitted a patient suffering from uncomplicated Myocardial Infarction 2 days ago. She referred the patient to her friend, an internist yesterday for she noted some irregularities in her pulse. Dr. Grajera ordered the dietician to give her patient soft diet for the next three to five days. Likewise she advised the patient not to mobilize or move around because it would cause more harm to the patients heart.

y The kind of care given by the above physician: y Comprehensive y Continuous y Coordination of care y A and B y A and C

family as a unit of care

prepared by: cynthia l. hipol, md, mph, fpafp

family, definitions
 in terms of affinity
- group of people related by blood, marriage or adoption, who live together in one household*
*UNITED NATIONS

family, definitions
Household: a group of persons

living under one roof and sharing the same kitchen and housekeeping arrangements

family, definitions, cont.



involve delineation of family structure, functions, composition, and affectionalities

family strengths,cont.


ability to provide for the familys physical, emotional , spiritual,and cultural needs
1.

- spiritual : sharing of basic beliefs - cultural : sharing of cultural values

family strengths, cont.



2. child - rearing

practices and discipline

1. respect each others views and decisions on child rearing practices 2. if a single parent, the capacity of a single parent to be consistent and effective in raising the children

family strengths, cont.

3. communication - the ability to communicate and express a wide range of emotions and feelings both verbally and non verbally

family strengths, cont.

 4.

support, security, and encouragement

4.1 provide each members with feelings of security and encouragement 4.2 balance in the pattern of family activities

family strengths, cont.

5.
-

growth : producing relationships;

the familys ability to maintain and build friendships and relationships in the neighborhood

family strengths, cont.

6.

responsible community

- relationships: the capacity of the family members to assume responsibility through participations in social, cultural or community activities

family strengths, cont.

7. self - help and accepting help - ability to seek and accept help when they think they need it 8. flexibility of family functions - and roles: family members ability to fill in for one another during times of illness or when needed

family strengths, cont.



crisis as a means of growth

9. -ability to unite and become supportive during a crisis or traumatic experience

family unity, loyalty and intra- family cooperation

10. - ability to recognize and use family traditions and rituals that promote unity and pride

family as a special unit

1. family membership is a lifelong involvement 2. shared attributes 3. sense of belonging 4. social expectations 5. built-in problems 6. family endures despite conflicts and built -in problems

why family as a unit of care

1. family is the social context for health care 2. patients problem is the familys problem 3. family is the greatest ally in treatment 4. patients family is present in patient interview

what is family care ?

1. taking care of all individuals in the family one by one 2. dealing with family as object of management 3. influencing family members to change factors affecting an individuals health

what family physicians need to know about families

1. understanding family structure and function 2. awareness of how families communicate 3. skills in observing how families operate 4. ability to relate family / individual 5. reinforce central function of family

Smilktein
5

1
Adaptation (coping)

Family in Functional Equilibrium

Stressful life event

Resources adequate

3 6
Resources Inadequate

Family in disequilibrium

Cycle of Family Function

8 Extrafamilial
resources

Crisis)

9 12
Terminal disequilibrium

Maladaptation (coping)

10

Pathological equilibrium

Stressful 11 life event

The Filipino Family

y Reliance on the family for love,

support, and refuge has historically been as much an economic necessity as it is a cultural tradition. practical trade off of autonomy for social security.

y the relationship to family is not just a

The Filipino Family

y

transcends socioeconomic, educational, and regional differences and is part of a collectivistic cultural orientation or way of perceiving the place of the individual in the social context (Gochenour, 1990; Santos, 1983).
emotional and material support; it also is the focus of one's primary duty and commitment. Dependence on, loyalty to, and solidarity with the family and kin group are of the highest priority (Okamura & Agbayani, 1991).

y is the source of one's personal identity and of

classification of families according to structure

   

nuclear family extended family polygamous family single - parent family

families according to structure

1.

nuclear family
married man and woman with their offspring (biological/adopted)  occupy a separate dwelling not shared with members of the family of orientation of either spouse  economically independent


families according to structure,cont

.

2. extended family includes three generations  shared responsibilities  maintenance of expressive and emotional relations beyond the nuclear family


There are three basic family systems

extended family
y Unmarried adult daughters and sons

typically remain in their parents' home and contribute to family support. such as grandparents, aunts, uncles, or cousins also may live in the same house and assume vital roles (Almirol, 1982; PAFEF, 1982; Santos, 1983).

y Additional extended family members

families according to structure,cont. 3.

single - parent family may result from:

 the loss of the spouse from death, divorce,

separation or desertion  from the out of wedlock birth of a child  from the adoption of a child

families according to structure, cont.

4.

blended family

 includes step parents, and

stepchildren  may be caused by separation, divorce, remarriage

basic family systems

y nuclear family which consists of a

husband, wife and children y extended family which brings together several generations in direct line and kinship ties built by marriage. y polygamous family which consists of a husband or wife and several spouses and their children;

y In Christian Filipinas, the family

is monogamous, one wife and one husband at a given time while polygamous or multiple wives in Muslim Filipino families is allowed. Nowadays, Muslims generally practice monogamy

yFilipino

Family (Mag-anak)

y Type of relationship

emphasized yConjugal : marital bond yConsanguinal: blood ties yPersonal virtues

y Choice

of marital partner, friends, godparents y Weakness/immorality/defects

Muslim Paternal dominance

Rural Filipino Paternal dominance with maternal decision making some areas Family is the property holder and source of labor Moderate strong discipline of children

Urban Filipino Paternal dominance with maternal decision making some areas Important in property; less effective is labor unit Combination of discipline and indulgence of treatment of children Individual marital choice with parental approval

Western Trend toward complete equality between husband & wife Economic role minor except as unit of consumption Trend toward the equality in parent-child relationship Romantic love all important with parental approval playing minor role Little and no chaperonage and no taboos

Family is the property holder and source of labor Strong discipline of children

Family choice of mate

Romantic love exalted subordinate to parental approval

No free association with opposite sex except for college educated

Chaperonage or group dating

Chaperonage giving way of dating

Muslim Double standard of morality

Rural Filipino Double standard of morality

Urban Filipino Double standard with queridas being challenge by wives

Western Tendency to a single standard for both sexes for fewer taboos for both. Prostitution available, mistresses rare Divorce obtainable on many grounds, but subject to legal restrictions and financial burdensome Small family includes only 2 generations and not collateral relatives. Low birth rate and low infant mortality

Divorce simple for husband; available for cause for wife

No divorce; legal separation with right of remarriage Consensual marriage not uncommon Extended family ties strong but usually separate dwellings. High birth rate; low infant mortality rate

Prostitution available; No divorce. Legal separation without right of remarriage Extended family weaker than in rural areas. Birth between that of Muslim and Western infant mortality low

Extended family often live together High birth rate; high infant morality rate

family set - up
 1.

democratic set up

 parents respect their childs decisions

and ideas, tolerance, understanding and permisiveness prevail

 2.

authoritarian set up

 conformity to parental guidance,

more punishments than praises

y Naming:

patronymic vs matronymic
y Authority y Patriarchal y Matriarchal y Equalitarian

Rules of Residence y Neolocal y Matrilocal y Patrilocal

"Traditional families and other social systems are highly authoritarian. Age, power, prestige, and wealth are the chief sources of authority" (Santos, 1983, p. 140). hierarchical system of authority that flows downward from oldest to youngest.

y Within the family, age determines a

Outside the family, other factors such as social class, professional status or official government affiliation, and ecclesiastical positions may supersede age as determining factors in the locus of authority.

y Egalitarian roles and relationships

between men and women are further reflected in family decision making processes.
y Family authority is based on respect

for age, regardless of sex.

y Family decisions are made only

after a consensus has been reached to ensure that the ultimate decision will be representative of and acted on by all family members.
y Family disagreements are avoided,

if possible; when disagreements do occur, they are kept strictly within the family (PAPEP, 1982).

y Although the father may be ostensibly

perceived as the main authority figure in the nuclear family, the mother has considerable authority and influence.

y She generally controls the finances,

may work full time (even with many children at home), and earns as much as or more than half the family income.

y Women enjoy high status in the family

and in the society at large. Bilateral lineage attests to this higher status of Filipinas compared with women in more patriarchal Asian countries.

y The long accepted phenomenon of

the "working mother" in the Philippines thus does not pose a drastic role change as it does for other recent Asian immigrant families in the United States (PAPEP, 1982).

basic areas of family function

 1. biologic  2. economic  3. educational  4. psychologic  5. socio - cultural or socialization

family relationship and interaction

y Children are the center of the parent's

concerns. They are viewed as an extension of the family and recipients of the family's good fortune. accept their point of view, rather than impose their authority on the child without consideration for the child's preferences or wishes.

y Parents are expected to persuade a child to

y The child, in turn, is expected to show

proper respect and obedience, to compromise, and to maintain good relationships with all other family members (PAPEP, 1982).

y In the Pilipino culture, the birth of

children is an expected and desired outcome of marriage. Most couples prefer to have children of both sexes, and there is typically no special preference for males over females. "gift from God," and a large family is proof of God's favor and blessing (Guthrie & Jacobs, 1966).

y Children are considered a special

I. ordinal position
1. first born - persevering, serious,
more responsive to adults, achievementoriented

2. middle child - optimistic ,

sociable, aggressive and competitive

. 3. youngest child - demanding,

outgoing, narcissistic, though by nature affectionate

II. parent child interaction / family relationship

 1.

rejecting parent submissive parent

 has an insecure, aggressive, sadistic, nervous,

stabborn and uncooperative child

 2.

 bears an aggressive, careless, disobedient and

uncooperative child

II.

parent - child interactions/ family relationships, cont.

3.

dominating parent

 gives out an uncooperative, tense, quarrelsome

and disinterested child 4.

absent father or mother home

- child is aggressive, neurotic, jealous, uncooperative, delinquent and less confident in the future and less able to trust adults

III. social class pattern of behavior

1. upper class family
closely- knit greater concern for maintaining the family name and prestige 2. middle class family believes in hard work, self reliance, initiative, independence, responsibility, economic security and self improvement through education 3. lower class family largely unemployed, sees life is a continuous process for survival and gives the impression of being to a life of frustration and defeat

Filipinos view education as y a "passport to good jobs, economic security, social acceptance, and as a way out of a cycle of poverty and lower class status, not only for their children, but for the whole family" (Santos, 1983, p. 146).
y family concern y an economic investment toward which family

members must contribute significant effort and often personal sacrifice.

y the individual is expected to assume the

responsibility of helping his or her parents finance the education of the next child.

major strengths of the Pilipino character:

y pakikipagkapwa-tao (having a regard for the

dignity and being of others),( Philippine Senate commissioned task force in 1988)

y family orientation, joy and humor, flexibility,

adaptability and creativity, hard work and industry, faith and religiosity, and ability to survive

(Licuanan, 1988). Each of these characteristics was summarized by Okamura and Agbayani (1991) and has been consistently identified by Church (1986) in a review of other studies on Pilipino personality values or ideals.

y Pakikipagkapwa-tao is manifested

among Filipinos in their basic sense of justice and fairness and concern for other's well being. Filipinos recognize the essential humanity of all people and regard others with respect and empathy.

yPakikisama represents both a

value and a goal that consists of maintaining good feelings in all personal interactions and getting along with others at all costs.

To avoid open displays of conflict and stressful confrontations, Filipinos may yield to
y group

opinion (even if it contradicts their own desires), y lavish extravagant praise on one another, y use metaphorical language rather than frank terms y hide negative feelings or depressed spirits beneath a pleasant demeanor, y smile when things go wrong, avoid saying "no," and refrain from expressing anger or losing their temper (Guthrie, 1968; Harper & Fullerton, 1994).

Hiya

y commonly translated as "shame," y a feeling of "inferiority,

embarrassment, shyness, and alienation which is experienced as acutely distressing" (Guthrie, 1968, p. 62). y integrally related to the concept of "face" and a preoccupation with how one appears in the eyes of others.

Hiya
y inculcated as a necessary part of a

child's development and used as a means to shape approved or desired behaviors.

y Thus, an individual's capacity for

appropriate behavior with authority figures is a reflection of one's family and upbringing and the fear of "losing face" (PAPEP, 1982).

utang na loob
y also is an integral aspect of maintaining group harmony and relationships that require the balancing of obligations and debts

V.

filipino values,

cultural ideals,

cont.

1. paggalang
- respect for the individual 2.

pagbabahala
- concern for work and other people

3. pananagutan - accountability for action taken 4. pagbabalikatan - sharing the burden with others
5. pagbabayanihan

- cooperation with teamwork 6. pagmamalasakit - solicituous concern for all

yNice to Know

THE FILIPINO FAMILY IN MODERN SOCIETY

y The process of modernization is catching up with the

Filipino family y Change must occur if the family is to survive in a changing world The Size of the Family

y In spite of family planning programs and education efforts

promoted y In spite of the economic difficulties of bringing up children, y their birth is welcomed;
o "Gifts from God o sent to help their parents obtain a better life through filial love, participation in income generating activities, insurance for their parents old age, and sources of strengthening family bonds.
y

typical family : five children, although three to four (urban) and four to five (rural) are considered by many parents as the ideal family size

y Economic Pressures on the Family y Effects of Poverty on the Family y The kinship system: y The extended kinship Group:

Changing pattern:compadrazgo. y Changing roles of men and woman y Double standard of morality

y Filipino Families must prepare

themselves for:
y a serious reexamination of values and

practices. y they will have to break with the past and adjust to the future. There is enough evidence of the viability of the Filipino family to make this adjustment and to ensure its survival. y The function of the family is being more and more absorbed by other social institutions such as the church and the school, but the family will remain as a great source of emotional and psychological satisfaction.

Filipino Family Values

People get strength and stability from their family. As such, many children have several godparents, the more the better. Concern for the extended family is seen in the patronage provided to family members when they seek employment. It is common for members of the same family to work for the same company, more likely than not. Jobs are hard to get and you can trust you relatives almost always. In fact, many collective bargaining agreements state that preferential hiring will be given to family members.