INTRODUCTION TO

FAMILY MEDICINE.

Contents:
1. Definition
2. Brief History
3. The 4 Cs & 4 Ps of Family Medicine
4. Why Primary Care?

DEFINITION OF
FAMILY MEDICINE
FAMILY MEDICINE/FAMILY PRACTICE/
GENERAL PRACTICE
is a medical specialty/component of the health
care system that provides
- initial, continuing, comprehensive &
coordinated medical care
- for all individuals, families & communities
- which integrates current biomedical,
psychological & social understanding of health.
RACGP definition.

FAMILY MEDICINE
It provides medical care across all
ages, sexes, diseases & parts of the
body.
Based on knowledge of the patient in
context of the family & community.
Emphasizing on disease prevention &
health promotion.
The main objective is to deliver
primary health care.

PRIMARY HEALTH CARE

Primary care is that care provided by
physicians specially trained for and
skilled in comprehensive first contact
and continuing care for persons with
any undiagnosed sign, symptom or
health concern (`the
undifferentiated patient) not limited
by problem origin (biological,
behavioral @ social), organ system
or diagnosis.

PRIMARY CARE
Primary Care includes health promotion,
disease prevention, health maintenance,
counseling, patient education, diagnosis &
treatment of acute care & chronic illnesses in a
variety of health care settings (e.g. Office,
inpatient, critical care, long-term care, home
care, daycare etc.)
Primary care is performed & managed by a
personal physician often collaborating with
other health professionals, & utilizing
consultation @ referral as appropriate.

PRIMARY CARE
Primary care providers aim to accomplish
cost-effective care for the patient by
coordination of health care services.
Primary care promotes effective
communication with patients & encourages
the role of the patient as a partner in
health care.
(AAFP definition.)
The terms Primary Care & Family Medicine
are NOT interchangeable.

SECONDARY CARE
Service provided by medical specialists who
generally do not have first contact with
patients
eg . Surgeons,orthopaedic specialists,
gynaecologists.

TERTIARY CARE
Specialist consultative care,( usually
on referral from Primary @
Secondary medical care provider ) by
specialists working in a centre that
has personnel & facilities for special
Ix.& Rx.
Eg. Oncology, Burns Centre,
Neurosurgery.

BRIEF HX. OF FAMILY

MEDICINE

Before late 19th century, FM was the only kind of medicine and most
physicians were Generalists.
Advancement of modern scientific and technological medicine
---------------------- subspecialties ( hospital based )
Specialization gained momentum with:1910 : Flexner Report ( U.S ) recommended that research, inpatient
teaching & consultant care should become the essence of medical
education.
Medical schools stopped training generalists ------------ increase
specialists & reduction in general physicians, restricting the
communitys access to a family physician & increased healthcare
cost.
Addressing the demand for high quality, cost-effective care & the
provision of continuity of care for the chronic diseases of the aging
population, American Medical Association appointed 2 committees
which produced 2 reports:
1. Millis Report
2. Report of the Willard Committee

 Both recommended:
The need for the Primary Physician of first
contact who delivers continuous and
comprehensive healthcare.
The creation for the specialty of family
practice.
Training by medical schools.
1969: American Board of Family Practice
established.
1973: The College of GPs of Malaysia.(AFPM)

The 4 Cs & 4Ps of FM.

4Cs
Community
Orientation.
Continuity of Care.
Comprehensive Care.
Coordination of Care.

4Ps
Primary @ First
Contact Care.
Personalized Care.
Preventive Care.
Patient Oriented Care.

Community Orientation.
Practice environment is the
community.
Exposed to the diseases and
problems of that community.
Sensitive to the culture of the
community.

Comparison between General/Community

Practice and Hospital Practice.
GENERAL PRACTICE
PATIENT-Person,
Ambulent.
PHYSICIAN-Friend,
Improvise, Peer.
Sensitive to the
community,
1 generalist discipline,
Cares for a broad range
of problems,
Deals with pt.- oriented
problems.

HOSPITAL PRACTICE
PATIENT- Patient,Dependent
PHYSICIAN-Official, Follows
Procedure, Hierarchical,
Isolated from Community.
Multiple Narrow Disciplines,
Cares for specific problems,
Deals with pathology
-oriented problems.

GENERAL PRACTICE VS HOSPITAL

PRACTICE
GP

DR.-PT. RELATIONSHIP
Continuing,
Based on Trust,
Persuasive,
Sees indv. as
member
of a family,
Culture specific.

HOSPITAL

DR.-PT. RELATIONSHIP
Episodic,
Dominant,
Authoritarian,
Sees indv. as
member
of the public,
Culture neutral.

CONTINUITY OF CARE
Caring for pt. from the first contact into the health
care system.
From prenatal till old age.
Caring for pt. in sickness & in health.
Initial care, emergency care, episodes of illness,
long-term care of chronic diseases, advice &
counseling, rehabilitation and palliative care.
(Palliative Care Active total care of pts. whose
disease is not responsive to curative rx.
----------the aim of care is to achieve the best Q of
life for the pts. & families.)

COMPREHENSIVE CARE
Provision of a wide variety of services,
covering the majority of the pt.s needs.
Convenient to the pt. as pt. doesn't need
to go to multiple providers for their
health care.
85-90% of pts. who presented to a FP are
managed without referral.
Accepting responsibility for organizing
care for the individual total health needs.

COMPREHENSIVE CARE
Includes - Maintenance of Health
- Prevention of Disease
Whole Person Care seeing individual as
a whole person.
Takes into consideration the social,
economic & psychological factors affecting
the individual & the organic pathology.
Appropriate referral.
Coordinates patients care.

COORDINATION OF CARE
The capacity to act as coordinator of all health
resources needed in the care of the patient.
The FP must:
- have a realistic overview of the pts problems
- be aware of the variety of services available
- select the one that is most appropriate
- taking into account pts background,
personality,
fears & expectations

COORDINATION OF CARE
The FP must also
- collect & interpret results of
studies &
referrals
- help pt comprehend what is
happening to
him.

PRIMARY @ FIRST CONTACT

CARE
FP is the point of first contact , the point of
entry of the pt into the health care system.
FP provides definitive care to the ill-defined,
undiagnosed pts. the undifferentiated pts.
Deals with problem complexes rather than
established disease.
FP makes total assessment of the pts
condition without subjecting pt to
unnecessary Ix., procedure & Rx.

Many reasons for the 1st

presentation:

Symptoms @ signs
Health advice
Prevention @ health promotion
Emergency care
Psychological @ emotional problems
Sometimes the reason for the visit is
not what the pt c/o HIDDEN
AGENDA, thus making the pt.
unsatisfied with the FPs explanation.

PERSONALISED CARE
Refers to the unique interaction between the pt
& the physician.
FP sees the pt as an indv. with a healthcare
need; not merely giving an episodic care of a
presenting complaint.
FP sees the pt many times over a long period of
time.
During this period, a comfortable & trusting
relationship is developed.
Many problems are addressed gradually over
many visits.

PERSONALISED CARE
Decision making is shared between the FP & the pt.
The FP develops close relationship with the pts
family & sees each member grows into the different
phases & roles of his/her life.
A FP also appreciates the complex mix of physical,
emotional & social elements in pt care.
Tumulty (1970):
Pts. consider a good physician to be one who shows
genuine interest in them, thoroughly evaluates their
problems, demonstrate compassion, understanding
& warmth & provides clear insight into what is wrong
& what must be done to correct it.

PREVENTIVE CARE
Means of promoting & maintaining health @
averting illness.
Involves the removal @ reduction of risks, early
diagnosis, early treatment, limiting complication
& maximising adaptation to disability.
Primary P Actions taken to avert the occurrence
of disease.
Secondary P-To stop @ delay the progression of D
Tertiary P Mx of established D so as to minimise
disability ( Rehabilitation)

PREVENTIVE CARE
ACTIVITIES
Prenatal counseling
Well baby check
RME
-pre-employment
-pre-sports
participation
Before
international travel
counseling

Smoking Cessation
Clinic
Immunization
Prescribing aspirin
to CAD pts.
Post stroke
rehabilitation
Obesity Clinic

PATIENT ORIENTED CARE

Whole person approach to Mx.
Different from Disease Oriented Care
- Hx-Phy.exam-Ix-Dx-Rx the Disease.
- Defined in terms of pathology.
- No signif.focus on feelings of pt suff.fr.dis.
Views pt from a broad perspective.
Takes into account Physiology, Physical Illness,
Emotional Health, Social, Occupational &
Environment the BIOPSYCHOSOCIAL approach.
Why pt oriented care? Why BPS approach?

The Familys Influence On

Health
Family relationships, dynamics &
social supports are strongly related
to healthy indv. Functioning.
Positive relationships support health
functioning.
Negative relationships contributes to
stress & adverse health outcomes.

Psychosocial Influences On
Health
Knowledge, attitudes, beliefs, emotions,
relationships & social environment interact to
affect the experience of illness @ well-being.
Work, school, home, social support network,
financial resources are factors that affect
health.
Addressing any of these can positively affect
functioning.
FP can work with pt to reduce stress & mobilize
social support resources.

WHY PRIMARY CARE?

Primary Care vs. Subspecialty Care:
Analysis of 15 y data fr. all 50 states of USA by Barbara
Starfield & colegues at John Hopkins U School of PH
concluded:
The higher the ratio of PCP to SS, the better the outcome:
- all-cause mortality, infant mortality, low birth
wt, life expectancy, self-rated health.
The greater the no. of PCP, the lower the mortality, the
greater the no. of subspecialist to population ratio, the
higher the mortality.

WHY PRIMARY CARE

Subspecialist-focused care tends to lead to higher costs & poorer
outcomes.
REASONS:
When pts have PCP as the regular source of care
Preventive services more consistently delivered.
Chronic diseases are better mx.
Ac.problems diagnosed & treated early.
Lower income gp greater access to care.
PCP active at community level to improve health care
resources & attitudes of both healthy
pt & pt with chr. dis.
Pt who goes to a variety of subspecialists without having a PCP, their
care tends to be fragmented & discontinous. Rx.focused on 1 body
system can have adverse impacts on other areas.

One third of the excessive cost is attributed

to performance of unnecessary procedure.

A FP, because of the ongoing

relationship with his pt is less under
pressure to exclude diagnostic
possibilities by use of expensive lab
& radiologic procedures than the
subspecialist who is unfamiliar with
the pt.

Hope you appreciate your exposure in the Primary

Care posting.

THE END.

Ref:

Rakel Textbook of FM-7th edition.

Essentials of FM-5th edition.
John Murtaghs GP-4th edition.
The Emergence of Family Practice-MK
Rajakumar.