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Principles

of

Family Medicine

Dr. Tita Menawati Liansyah, M.Kes

FAMILY MEDICINE

Described as a body of knowledge about the problems encountered by family physician

Factual knowledge, skill & techniques

PENGERTIAN DOKTER KELUARGA

Dokter yg menyelenggarakan pelayanan

kesehatan personal, tingkat pertama,

menyeluruh dan berkesinambungan kpd

pasiennya yg terkait dgn keluarga,

komunitas serta lingkungan dimana

pasien tsb berada.

FAMILY PRACTICE

The American Academy of Family Physicians(AAFP) and the American Board of FamilyPractice (ABFP)

".....the medical specialty that provides continuing and comprehensive health care for the individual and the family. It is the specialty in breadth that integrates the biological, clinical and behavioural sciences. The scope of family practice encompasses all ages, both

sexes, each organ system and disease entity."

DOKTER KELUARGA

nakes sbg kontak pertama pasien di fasilitas yankes

menyelesaikan semua masalah kes yg dihadapi

jenis penyakit, organologi, gol. Usia & JK

secara paripurna pendekatan holistik&bersinambungan

koordinasi & kolaborasi dgn profesional kes lainnya

prinsip pelayanan yg efektif, efisien & utamakanpencegahan menjunjung tinggi tanggung jawabprofesional, hukum, etika & moral.

Sedini & sedpt mungkin

TUJUAN PELAYANAN KEDOKTERAN

KELUARGA

Terselesainya masalah kesehatankeluarga dan terciptanya keluarga yang partisipatif, sehat badan, jiwa, sosial

dan sejahtera yang memungkinkan setiapanggota keluarga hidup produktif secarasosial dan ekonomi (McWhinney, 2009).

4 pilar prof:

Perilaku (sbg penyelenggara pel. primer)

Ilmu (Ilmu Ked. Layanan Primer paripurna)

Keterampilan(Klinis DLP paripurna)

Kinerja(sbg penyelenggara pelayanan primer)

Dijabarkan

7 area kompetensiDokter Diterapkan dalam

bentuk:

9 prinsip pelayanan

DK

the

five

star

doctor

Wujud pelayanan

kesehatan

bermutu

AREA KOMPETENSI DOKTER

1. Keterampilan Komunikasi efektif

2. Keterampilan klinik dasar

3. Keterampilan menerapkan dasar2 ilmu biomedik,ilmu klinik, ilmu perilaku dan epidemiologi dalampraktek kedokteran keluarga

4. Keterampilan mengelola masalah kes pd individu,keluarga / masy. secara komprehensif, holistik,bersinambung, terkoordinir & bekerja sama dlmkonteks Pelayanan Kesehatan Primer

5. Mampu memanfaatkan, menilai secara kritis danmengelola informasi

6. Mampu mawas diri dan belajar sepanjang hayat

7. Sadar etika, moral, dan profesionalisme dalampraktik

Its best to start with the principles that govern our

action.

Lets describe it..!!!

DESCRIBING FAMILY MEDICINE

1. Personal care

Its not limited by the type of health problem

The commitment hasnt defined end point

Available in any health prob. in a person sex/age??

Can never say im sorry but ur illness isnt in my field

2. First contact care

the family physician (FP) sees every contact with his orher patients as an opportunity for prevention of disease /promotion of health.

3. Comprehensive care

Comprehensive care means making an assessment of thepatients problem in physical, emotional and sosial termsand managing the patient as an individual in the family andcommunity, using both curative and preventive measures

curative measuress( advice,relieve sympom,early

diagnosis and treatment, minor surgery etc) and preventive

measures ( primary, secondary and tertiary), palliative care

4. CONTINUITY OF CARE

5 dimension : interpersonal, chronological,geographic, interdisiplinary, informational

responsibility : Is the Key word in all importantrelationship

The advantages of continuing care :1. More economical because of the doctors

previous knowledge of the patient, they willnot need expensive investigations to help inthe diagnosis, unlike a specialist who may beseeing the patient for the first time.A study in the USA showed that people whohave their own family doctor pay less formedical care, undergo less operations andundergo less hospitalizations, than those whoshop from one specialist to another.

2. Patient compliance is better because of the longterm doctor patient relationship, patients havefaith and confidence in their own family doctor whohas helped them get over many problems in the past.They would therefore comply more readily with thetreatment given.

3. Continuity of care allows the doctors to use his ownpersonality as a therapeutic tool. As Michael Balintstated in his book the doctor, his patient and theillness" the doctor is the most powerful drug ingeneral practice. It is the manner in which doctorsprescribe themselves by talking to patients withconcern, that play a major role in a patient'srecovery

5. COORDINATION OF CARE

FP has an important role to play in making use ofall health care resources in the hospital/ in thecommunity for the benefit of patients.

Although the FP's clinical skills& personalknowledge of the patient makes it easy to dealwith most problems brought by the patient, therewill be some instances when the patient needs tobe referred to a specialist who has highlyspecialised skills in a narrow field. Sometimes itmay be necessary to refer the patient to analternative health resource in the community. Inthis way the family doctor acts as the coordinatorof a patient's medical and health care.

To be the coordinator, the FP must firstly haveabroad knowledge of the patient and his or herproblem, the family, the nature and severity of theillness, the patient's fears and reaction to illness,personality and expectations and the patient'ssocioeconomic background.

Secondly, the doctor must know the differentspecialists who are available who could deal with theproblem, where they could be consulted andhospitals and other health resources in thecommunity.

Having a knowledge in all these areas, the familyphysician is the best person to select the mostappropriate specialist or health facility to refer thepatient to and in this way will coordinate thepatient's health care.

6. PREVENTIVE CARE

FP is ideally placed to practise preventive care,although most patients consult the doctor only whenthey are ill.

An opportunity arises almost at each and everyconsultation to give health education.

Other types of primary prevention carried out bythe family physician are immunization and familyplanning etc.

On the other hand, the family physician may detectthe early stages of an illness where early diagnosiscan help to cure,& that would be practisingsecondary prevention eg. anaemia in a pregnantmother.

If the patient has a chronic illness which is alreadyestablished such as a hemiplegia, further disabilitycan be prevented by making arrangements for thepatient to have physiotherapy and that would bepractising tertiary prevention.

FP also sees patients as a population at risk. Thedoctor would carry out case finding and screeningprocedures to identify patients in the asymptomaticstage of the disease, before symptoms and signsappear eg. checking of BP in a middle aged patientwho consults for some other problem.

FP also practise anticipatory guidance& preventivecounselling. By having a knowledge of the stressorswhich could occur at the different stages of thefamily life cycle, FP could anticipate problemsbefore they arise and give preventive counselling.

7. Memandang pasien sbg bag. Integral darikeluarga, komunitas, lingk.

8. Mudah diaudit dan akuntabel.

9 Sadar biaya, etika, moral dan hukum.

Peran keluarga dlm meningkatkan drjd kes:

Merawat seluruh anggota kel

Melibatkan kel sbg objek pel.kes

Melibatkan anggota kel dlm merubah faktor2yg akan mempengaruhi kes individu

LAYANAN KESEHATAN YANG DIBERIKAN

OLEH DOKTER KELUARGA

Peningkatan derajat kesehatan melalui

konsultasi kesehatan keluarga dan ceramah

tentang kesehatan.

Pencegahan penyakit melalui pendidikan

kesehatan bagi pasien, keluarga dan

masyarakat.

Melakukan tindakan medis berupa imunisasi,

pemantauan kesehatan ibu dan anak, keluarga

berencana, dsb.

Deteksi dan pengobatan dini penyakit.

LANJUTAN

Mencegah cacat atau keterbatasan pada

pasien yang sudah sakit penyakitkronis yang berpotensi menimbulkan

kecacatan atau keterbatasan.

Berusaha melakukan rehabilitasi

Bekerja sama dengan unit rehabilitasi

medik rumah sakit untuk melakukan

upaya rehabilitasi secara komprehensif.

(Konsorsium Kedokteran Keluarga Indonesia, 2012):

PERBEDAAN ANTARA DK DGN DPU

Cakupan layanan lbh luasSifat pelayanannya menyeluruh &paripurna, tdk terbatas dgn ygdikeluhkan sajaCara pelayanannya kasusperkasus, kontinyu, pengamatansepanjang hayatJenis layanan Lebih bersifatmeningkatkan taraf kes, preventif,kuratif & rehabilitatifPeran keluarga selaludipertimbangkan dan dilibatkanPromotif dan preventif Menjadiperhatian utamaDokter-pasien-keluarga-konsultan

Cakupan layanan terbatas

Sifat pelayanannya sesuai dgnkeluhan

Cara pelayanannya kasusperkasus, hanya pengamatansesaat

Jenis layanan lebih kearahkuratif, hanya mengobatipenyakit yg ditemukan

Peran keluarga kurangdipertimbangkan

Promotif dan preventif tidakselalu jadi perhatian

Dokter dengan pasien

DK DPU

CUMULATIVE KNOWLEDGE OF PATIENTS

Continous & comprehensive care allows the FP to

build up a capital knowledge about patients

& families.

Knowledge accumulate slowly during the 1st

few months of relationship

Increases sharply between 3 and 12 month

Flatten out somewhat, but still increases

steadly during the next few years

The freq. of contact also contributes to the accumulation of knowledge

prior knowledge reduced the duration of consultation in 40 % of visits

The major impact being at 4 5 visits/ year

THE ROLE OF GENERALIST

6 misconception about the roles of generalist &specialist in medicine :

1. The GP has to cover the whole field of medicalknowledge

2. In any given field of medicine, specialist alwaysknow more than the GP

3. By specializing, one can eliminate uncertainty

4. Only by specializing can one attain depth ofknowledge

5. As science advances, the load of informationincreases

6. Error in medicine is usually caused by lack ofinformation

1. THE GP HAS TO COVER THE WHOLE FIELDOF MEDICAL KNOWLEDGE

GPs knowledge is just as selective as Sp.s

Like Sp., GP. Select the knowledge to fulfill theirrole.

Ex : SAH

i. (GP needs to know the symptom& the cuesmake early Dx)

ii. (Neurosurgeon needs to know the pathology&the techniques of investigation and surgicalth/ )

2. IN ANY GIVEN FIELD OF MEDICINE,SPECIALIST ALWAYS KNOW MORE THAN THE GP

Sp become knowledgeable about rarer variants of

disease because theyre selected for them by GP

GP become knowledgeable about the common

condition that rarely reach the Sp.

FP sometimes encounter this when underpressure

Consult a Sp.

Even thougt they know that they are infull command of the situation

3. BY SPECIALIZING, ONE CAN ELIMINATEUNCERTAINTY

The only way to eliminate uncertainty is.

Reduce problm. to their simplest elements &

isolate them from surroundings

4. ONLY BY SPECIALIZING CAN ONE ATTAINDEPTH OF KNOWLEDGE

This fallacy confuses depth with detail

Depth of the knowledge depends on thequality of the mind not on itsinformation content

6. ERROR IN MEDICINE IS USUALLY CAUSED BYLACK OF INFORMATION

a. Very little medical error is caused by byphysician being ill informed

b. Much more is caused by :

Insensitivity

Carelessness

Failure of listen

Administrative inefficiency

Failure of communication

c. We want FP to be well informed, but this willnot guarantee medical care of high quality.

d. FP must know how to obtain information dan howto use it

All FP dont have identical knowledge and skill

Rural FP required to do more prosedure

Urban FP develop greater knowledge &expertise in management of drug dependencyfor expl.

Family Physician may be differentiated, butfamily medicine shouldnt fragment.

KEY CONCEPTS

Family medicine seeks to provide personal, primary,continuing care and comprehensive care:

Personal care reiterates the relationship of thepatient to his doctor as a person. The doctor plays arole as his personal doctor, mentor and advisor in aprofessional capacity. There is a need to keep therelationship at all times professional.

Primary care is first contact care. The boundariesof primary care in any community are fixed at oneextreme by the patients who decide that problemsthey wish to bring to the professional and at theother extreme by the availability of secondary carefacilities.

KEY CONCEPTS

Continuing care is the use of the same doctor orsame facility for an ongoing problem. This has theadvantage of continuity of medical records and themorbidity experience of the patient.

Comprehensive care depicts the wide scope of carethat i. covers all age groups

ii. spans promotive, preventive, curative, rehabilitative andpalliative care

iii. deals with not only physical but also social andpsychological problems. This is "whole person" medicine orholistic care.

In fulfilling the broad scope of care, the family doctormay have to enlist the help of his specialistcolleagues as well as the primary health care team.

SKILLS IN FAMILY MEDICINE

communication and counselling skills problem solving skills of the undifferentiated illness skills of cost effective management in the context

of family and community. Preventive skills are also necessary as family

medicine is concerned with the prevention ofdisease and maintenance of health of individuals andfamilies in the community.

Family medicine requires an attitude that respectsthe patient as a person who needs your help, and notas a disease that has to be cured.

SIR WILLIAM OSLER STATED IN 1904,

" It is much more

important to know

what sort of patient

has a disease than

what sort of disease a

patient has"

KRITERIA THE FIVE STAR DOCTOR

1. Care provider (penyelenggara pelayanankesehatan)

mempertimbangkan pasien secara holistik (sbgseorang individu, bag. integral dari keluarga,komunitas, lingk)

menjalankan pelayanan kes. yg berkualitastinggi, komprehensif, kontinyu, personal, dlmjangka wktu yg panjang. Dan wujud hub.profesional Dokter-pasien yg slg menghargaidan mempercayai.

pel. komprehensif yg manusiawi namun ttp dptdiaudit & dipertanggungjawabkan.

THE FIVE STAR DOCTOR

2. Decision maker melakukan pemeriksaan, pengobatan dan

pemanfaatan tek. Kedokteran bdsrkan kaidahilmiah yg mapan

kepentingan pasien sepenuhnya.

membuat keputusan klinis yang ilmiah danempatik

dgn mempertimbangkan harapan pasien, nilai etika, & cost effectiveness

THE FIVE STAR DOCTOR

3. Communicator

- Mampu memperkenalkan pola hidupsehat melalui penjelasan efektif shg memberdayakan pasien & keluargautk meningkatkan & memeliharakes.nya sendiri

- Memicu perubahan cara berfikirmenuju sehat dan mandiri kpd pasiendan komunitasnya

THE FIVE STAR DOCTOR

4. Community leader

- Yg memperoleh kepercayaan darikomunitas pasien yg dilayani

- menyearahkan kebutuhan kes individu &komunitasnya

- memberikan nasihat kpd kelompok,penduduk

- melakukan keg. atas nama masy.

- Menjadi panutan masy.

THE FIVE STAR DOCTOR

5. Manager

dpt bekerja secara harmonis dgn individu danorganisasi didlm maupun diluar sist. Kes agardpt memenuhi kebutuhan pasien komunitasnyaberdasarkan data kes. Yg ada

menjadi dokter yg cakap memimpin klinik/institusi kes, sehat, sejahtera dan bijaksana

INDIKATOR KEBERHASILAN PELAYANAN

KEDOKTERAN KELUARGA

Meningkatnya status kesehatan keluarga kesehatan badan, jiwa dan sosial seluruh anggotakeluarga.

Meningkatnya peran serta anggota keluargakhususnya penanggung jawab keluarga dalammenyelesaikan masalah kesehatan dirinya, sosialmaupun lingkungan keluarganya.

Adanya kemampuan keluarga untuk mengatasipermasalahannya.

THANK YOUJika ada hal yang ingin di diskusikan

silahkan menghubungi saya di :

Email ; titamenawati@gmail.com

Twitter : @dr_tita