Principles of Family Medicine
Dr. Tita Menawati Liansyah, M.Kes
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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 Family Practice (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 Sedini & sedpt mungkin
secara paripurna → pendekatan holistik& bersinambungan koordinasi & kolaborasi dgn profesional kes lainnya
prinsip pelayanan yg efektif, efisien & utamakan pencegahan → menjunjung tinggi tanggung jawab profesional, hukum, etika & moral.
TUJUAN PELAYANAN KEDOKTERAN KELUARGA
Terselesainya masalah kesehatan keluarga dan terciptanya keluarga yang partisipatif, sehat badan, jiwa, sosial dan sejahtera yang memungkinkan setiap anggota keluarga hidup produktif secara sosial dan ekonomi (McWhinney, 2009).
the five star doctor
Dijabarkan→
7 area kompetensi Dokter
4 pilar prof: • • • •
Diterapkan dalam bentuk: 9 prinsip pelayanan DK
Perilaku (sbg penyelenggara pel. primer) Ilmu (Ilmu Ked. Layanan Primer paripurna) Keterampilan(Klinis DLP paripurna) Kinerja(sbg penyelenggara pelayanan primer)
Wujud pelayanan kesehatan bermutu
AREA KOMPETENSI DOKTER 1. 2. 3.
4.
5. 6. 7.
Keterampilan Komunikasi efektif Keterampilan klinik dasar Keterampilan menerapkan dasar2 ilmu biomedik, ilmu klinik, ilmu perilaku dan epidemiologi dalam praktek kedokteran keluarga Keterampilan mengelola masalah kes pd individu, keluarga / masy. secara komprehensif, holistik, bersinambung, terkoordinir & bekerja sama dlm konteks Pelayanan Kesehatan Primer Mampu memanfaatkan, menilai secara kritis dan mengelola informasi Mampu mawas diri dan belajar sepanjang hayat Sadar etika, moral, dan profesionalisme dalam praktik
DESCRIBING FAMILY MEDICINE
It’s best to start with the principles that govern our action…. Let’s describe it..!!!
1. Personal care It’s not limited by the type of health problem
Available in any health prob. in a person
sex/age??
Can never say “im sorry but ur illness isnt
in my field”
The commitment hasn’t defined end point
2. First contact care
the family physician (FP) sees every contact with his or her patients as an opportunity for prevention of disease / promotion of health.
3. Comprehensive care
Comprehensive care means making an assessment of the patient’s problem in physical, emotional and sosial terms and managing the patient as an individual in the family and community, 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 important relationship The advantages of continuing care : 1. More economical because of the doctor’s previous knowledge of the patient, they will not need expensive investigations to help in the diagnosis, unlike a specialist who may be seeing the patient for the first time. A study in the USA showed that people who have their own family doctor pay less for medical care, undergo less operations and undergo less hospitalizations, than those who shop from one specialist to another.
2. Patient compliance is better because of the long term doctor patient relationship, patients have faith and confidence in their own family doctor who has helped them get over many problems in the past. They would therefore comply more readily with the treatment given. 3. Continuity of care allows the doctors to use his own personality as a therapeutic tool. As Michael Balint stated in his book “ the doctor, his patient and the illness" the doctor is the most powerful drug in general practice. It is the manner in which doctors prescribe themselves by talking to patients with concern, that play a major role in a patient's recovery
5. COORDINATION
OF CARE
FP has an important role to play in making use of all health care resources in the hospital/ in the community for the benefit of patients. Although the FP's clinical skills& personal knowledge of the patient makes it easy to deal with most problems brought by the patient, there will be some instances when the patient needs to be referred to a specialist who has highly specialised skills in a narrow field. Sometimes it may be necessary to refer the patient to an alternative health resource in the community. In this way the family doctor acts as the coordinator of a patient's medical and health care.
To be the coordinator, the FP must firstly have abroad knowledge of the patient and his or her problem, the family, the nature and severity of the illness, the patient's fears and reaction to illness, personality and expectations and the patient's socioeconomic background.
Secondly, the doctor must know the different specialists who are available who could deal with the problem, where they could be consulted and hospitals and other health resources in the community. Having a knowledge in all these areas, the family physician is the best person to select the most appropriate specialist or health facility to refer the patient to and in this way will coordinate the patient's health care.
6. PREVENTIVE CARE FP is ideally placed to practise preventive care, although most patients consult the doctor only when they are ill. An opportunity arises almost at each and every consultation to give health education. Other types of primary prevention carried out by the family physician are immunization and family planning etc. On the other hand, the family physician may detect the early stages of an illness where early diagnosis can help to cure,& that would be practising secondary prevention eg. anaemia in a pregnant mother.
If the patient has a chronic illness which is already established such as a hemiplegia, further disability can be prevented by making arrangements for the patient to have physiotherapy and that would be practising tertiary prevention. FP also sees patients as a population at risk. The doctor would carry out case finding and screening procedures to identify patients in the asymptomatic stage of the disease, before symptoms and signs appear eg. checking of BP in a middle aged patient who consults for some other problem. FP also practise anticipatory guidance& preventive counselling. By having a knowledge of the stressors which could occur at the different stages of the family life cycle, FP could anticipate problems before they arise and give preventive counselling.
7. Memandang pasien sbg bag. Integral dari keluarga, 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 faktor2 yg 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 → penyakit kronis 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 DK Cakupan
layanan lbh luas Sifat pelayanannya menyeluruh & paripurna, tdk terbatas dgn yg dikeluhkan saja Cara pelayanannya kasus perkasus, kontinyu, pengamatan sepanjang hayat Jenis layanan Lebih bersifat meningkatkan taraf kes, preventif, kuratif & rehabilitatif Peran keluarga selalu dipertimbangkan dan dilibatkan Promotif dan preventif Menjadi perhatian utama Dokter-pasien-keluarga-konsultan
DPU
Cakupan layanan terbatas
Sifat pelayanannya sesuai dgn keluhan Cara pelayanannya kasus perkasus, hanya pengamatan sesaat Jenis layanan lebih kearah kuratif, hanya mengobati penyakit yg ditemukan
Peran keluarga dipertimbangkan
kurang
Promotif dan preventif tidak selalu jadi perhatian Dokter dengan pasien
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
The major impact being at 4 – 5 visits/ year prior
knowledge reduced the duration of consultation in 40 % of visits
THE ROLE OF GENERALIST 6 misconception about the roles of generalist & specialist in medicine : 1. The GP has to cover the whole field of medical knowledge 2. In any given field of medicine, specialist always know more than the GP 3. By specializing, one can eliminate uncertainty 4. Only by specializing can one attain depth of knowledge 5. As science advances, the load of information increases 6. Error in medicine is usually caused by lack of information
1. THE GP
HAS TO COVER THE WHOLE FIELD OF MEDICAL KNOWLEDGE
GP’s knowledge is just as selective as Sp.”s Like Sp., GP. Select the knowledge to fulfill their role. Ex : SAH i. (GP needs to know the symptom& the cues→ make early Dx) ii. (Neurosurgeon needs to know the pathology &the techniques of investigation and surgical th/ )
2.
ANY GIVEN FIELD OF MEDICINE, SPECIALIST ALWAYS KNOW MORE THAN THE GP
IN
Sp become knowledgeable about rarer variants of disease because they”re selected for them by GP GP become knowledgeable about the common condition that rarely reach the Sp.
FP sometimes encounter this when underpressure Even thougt they know that they are in full command of the situation
Consult a Sp.
3. BY
SPECIALIZING, ONE CAN ELIMINATE UNCERTAINTY
The only way to eliminate uncertainty is….
Reduce problm. to their simplest elements & isolate them from surroundings
4. ONLY
BY SPECIALIZING CAN ONE ATTAIN DEPTH OF KNOWLEDGE This
fallacy confuses depth with detail
Depth
of the knowledge depends on the quality of the mind… not on its information content
6. ERROR
IN MEDICINE IS USUALLY CAUSED BY LACK OF INFORMATION
a. Very little medical error is caused by by physician 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 will not guarantee medical care of high quality. d. FP must know how to obtain information dan how to use it
All FP don’t have identical knowledge and skill
Rural FP → required to do more prosedure
Urban FP → develop greater knowledge & expertise in management of drug dependency for expl. Family Physician may be differentiated, but family medicine shouldn’t fragment.
KEY CONCEPTS Family medicine seeks to provide personal, primary, continuing care and comprehensive care: Personal care reiterates the relationship of the patient to his doctor as a person. The doctor plays a role as his personal doctor, mentor and advisor in a professional capacity. There is a need to keep the relationship at all times professional. Primary care is first contact care. The boundaries of primary care in any community are fixed at one extreme by the patients who decide that problems they wish to bring to the professional and at the other extreme by the availability of secondary care facilities.
KEY CONCEPTS
Continuing care is the use of the same doctor or same facility for an ongoing problem. This has the advantage of continuity of medical records and the morbidity experience of the patient. Comprehensive care depicts the wide scope of care that i. covers all age groups ii. spans promotive, preventive, curative, rehabilitative and palliative care iii. deals with not only physical but also social and psychological problems. This is "whole person" medicine or holistic care.
In fulfilling the broad scope of care, the family doctor may have to enlist the help of his specialist colleagues 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 of disease and maintenance of health of individuals and families in the community. Family medicine requires an attitude that respects the patient as a person who needs your help, and not as 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 pelayanan kesehatan) mempertimbangkan pasien secara holistik (sbg seorang individu, bag. integral dari keluarga, komunitas, lingk) menjalankan pelayanan kes. yg berkualitas tinggi, komprehensif, kontinyu, personal, dlm jangka wktu yg panjang. Dan wujud hub. profesional Dokter-pasien yg slg menghargai dan mempercayai.
pel. komprehensif yg manusiawi namun ttp dpt diaudit & dipertanggungjawabkan.
THE FIVE STAR DOCTOR 2. Decision maker melakukan pemeriksaan, pengobatan dan pemanfaatan tek. Kedokteran b’dsrkan kaidah ilmiah yg mapan dgn mempertimbangkan harapan pasien, nilai etika, & cost effectiveness kepentingan pasien sepenuhnya.
membuat keputusan klinis yang ilmiah dan empatik
THE FIVE STAR DOCTOR 3. Communicator - Mampu memperkenalkan pola hidup sehat melalui penjelasan efektif → shg memberdayakan pasien & keluarga utk meningkatkan & memelihara kes.nya sendiri - Memicu perubahan cara berfikir menuju sehat dan mandiri kpd pasien dan komunitasnya
THE FIVE STAR DOCTOR 4. Community leader - Yg memperoleh kepercayaan dari komunitas 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 dan organisasi didlm maupun diluar sist. Kes agar dpt memenuhi kebutuhan pasien komunitasnya berdasarkan 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 anggota keluarga. Meningkatnya peran serta anggota keluarga khususnya penanggung jawab keluarga dalam menyelesaikan masalah kesehatan dirinya, sosial maupun lingkungan keluarganya. Adanya kemampuan keluarga untuk mengatasi permasalahannya.
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