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:

FIVE-STAR DOCTORHealth care provider

Decision maker

Manager

Community leader

Communicator

Modifikasi Five-star Doctor menjadi Five-star Family Doctor oleh Philippine Academy of Family Physicians (PAFP, 2001)

FIVE-STAR FAMILYDOCTORHealth care provider

Counselor/Advocate

Administrator/ Manager

Life-long learner/ researcher

Health educator

Bio-medical-clinical science

CME & CPD, IT EBM & Research

Health Promotion, Disease Prevention &Life-style modification

Health Organization &Management

Communication &Counseling Skills

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)

(Doherty & Baird, 1980)PhysicianFamilyPatient

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 modelHolistic DiagnosisHolistic 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.

PatientPresentscuesThe Patient Centered Clinical Method

PersonalbehaviorPsycho-socio-EconomicEnvironmentHuman biologyPhysicalenvironmentThe Mandala of Health:A model of human ecosystemCultureCommunitylifestyleworkSickcaresystemHuman-Made EnvironmentBiospherespiritbodymind

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 Patient Holistic History Taking Comprehensive Management Holistic Diagnosis

Investigations

Physical ExamHistory of Patient:Personal social historyDisease & illness Risk factors Family assessmenttoolsMedical DiagnosisFamily SCREEMFamily APGARFamily Life LineFamily Life Cycle Family Map Genogram Psychosocial InterventionMedical Intervention Based on EBMPsychosocial DiagnosisLPI: level 2-4 Preventive Measures Impact of Illness

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 Laki- Laki 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

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