Orientation to the Family Medicine Clerkship

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Orientation to the Family Medicine Clerkship

• Darwin Deen, MD, MS
• 2004-2005

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IOM Definition of Primary Care

• Generalist health care is continuous,
  comprehensive, and coordinated medical care
  provided to a population undifferentiated by age,
  gender, or organ system.

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Primary care is not a discipline or specialty but
a function that is essential as the foundation of
a successful, sustainable health care system.
Institute of Medicine
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Characteristics of Primary Care

• First Contact- undifferentiated by illness,
  triage function, case manager (coordinates the
  patients care regardless of where provided or by
  whom)
• Continuous- over time (longitudinal), not limited
  by age group
• Comprehensive- preventive, diagnostic and
  curative/therapeutic

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Patients and their Doctors

• In 1987 the National Medical Expenditure Survey
  reported that 82 of Americans has a usual
  source of care.
• In 1994 80 of adults completing the General
  Social Survey reported a regular personal
  doctor.
• In 1996 the Medical Expenditure Panel Survey
  found that 77 of households had a usual primary
  care provider

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Primary Care Competencies (USDHHS)

• Health promotion and disease prevention
• Assessment and diagnosis of common symptoms and
  signs
• Management of common acute and chronic medical
  conditions
• Identification of and appropriate referral for
  other health services

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Crossing the Quality Chasm

• Characteristics of high-quality healthcare
• safe
• timely
• effective
• efficient
• patient-centered
• equitable

Institute of Medicine 2002
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Future of Family Medicine

• The attributes of Family Medicine are
• continuity,
• comprehensiveness,
• first contact,
• community, and
• family.

http//www.annfammed.org/cgi/content/full/2/suppl_
1/s3
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Fundamental Principles of Family Medicine

• Access to Care
• Continuity of Care
• Comprehensive Care
• Coordination of Care
• Contextual Care

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Access to Care

• Access issues deal with how patients use the
  health care system
• (including who, when why)

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Continuity of Care

• Continuity deals with how doctor-patient
  relationships develop, change, and end
• Dimensions include chronologic and geographic
  continuity, and continuity of generalism and for
  families

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Comprehensive Care

• Deals with the scope of practice and extent of
  services delivered

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Coordination of Care

• How physicians organize and manage the care they
  deliver.
• Health promotion and preventive services
  including screening and immunizations.
• The specialty referral process care for
  special populations.

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Contextual Care

• How the health care problems of the individual
  patients are placed in a context (biomedical,
  psychological, individual, family, community, and
  social). What the illness means to the patients
  life.

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Who is in Control of the Environment surrounding
a locus of care?
Environmental Aspect Hospital Office
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DFSM Clerkship

• Three Components
• Clinical Experience
• Community Experience
• Case-based discussions and Didactics

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The Ecology of Medical Care
1,000 People In Community
750 Will Report an Illness/Injury
250 Will Seek Care
9 Admitted
3 Referred
1 University Admission
White KL, et al, N. Engl J Med, 1961 265885-92
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1,000 Persons
800 Report Symptoms
327 Consider Seeking Medical Care
217 Visit physicians office (113 primary care
physician)
65 Visit complimentary or alternative medical
provider
21 Visit a hospital outpatient clinic
14 Receive home health care
13 visit emergency dept.
lt1 is hospitalized in an academic medical center
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Orientation to TOPICS Curriculum
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Future of Family Medicine

• The core attributes of family medicine are
  organized into 4 discrete domains
• 1) the management of knowledge and information,
• 2) the management of relationships,
• 3) the management of processes, and
• 4) cultural proficiency.

http//www.annfammed.org/cgi/content/full/2/suppl_
1/s3
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5 Types of Visits

• New Problem (Acute Care)
• Checkup (Health Maintenance)
• Chronic Illness (Routine Follow-up)
• Psychosocial
• Behavior Change

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Major Tasks

• Physician Information Processing
• Data acquisition and synthesis
• Patient-physician relationship development
• Integration of information and relationship
• Lifelong learning

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Major Tasks

• Physician Information Processing
• How does the history-taking or other data
  gathering differ for each different type of
  visit?
• Patient-physician relationship development
• How do different types of visits promote
  relationship development?
• Integration of information and relationship
• Lifelong learning
• How are your learning needs different for each
  type of visit?

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What are the tasks that need to be accomplished
in the primary care ambulatory setting?

• Making a new diagnosis
• Patient presents with an undiagnosed complaint or
  set of symptoms.
• How do we evaluate a symptom?
• How do we decide who needs further evaluation
  (tests) or referral?

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What are the tasks that need to be accomplished
in the primary care ambulatory setting?

• 2. Health Maintenance visits
• These visits should be seen as an opportunity to
  accomplish primary prevention.
• What interventions are indicated for patients in
  each age/sex group?
• What interventions are evidence-based? How do we
  know?
• What interventions are cost-effective? (e.g.
  breast self-exam)
• How do we prioritize? (e.g. dietary counseling in
  unselected patients)
• This examines how we know what to do and what
  resources are available to help us.

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What are the tasks that need to be accomplished
in the primary care ambulatory setting?

• 3. Follow-up visit for ongoing treatment of a
  known medical problem.
• e.g. follow-up of a previously diagnosed acute
  problem or for chronic disease management
• What is important in the management of this/these
  chronic disease/s?

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What are the tasks that need to be accomplished
in the primary care ambulatory setting?

• 4. Emotional support how do we help patients in
  need of acute or ongoing psychological treatment?
• BATHE technique
• SPEAK treatment model
• When how to refer

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What are the tasks that need to be accomplished
in the primary care ambulatory setting?

• 5. Behavior Change visit
• For primary or secondary prevention and/or
  patient education
• Self-care
• Chronic disease management

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For each of the visit types, what information do
you need to successfully handle this visit?

• Information from the patient in the form of
• history
• physical examination findings
• medical record
• laboratory tests
• imaging studies
• provocative tests (stress tests, PFTs)
• or invasive testing (cardiac cath, biopsy, etc)
• Information from the medical literature
• Information from consultants
• Patient education material

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New problem

• Assess presenting complaint
• History and physical exam
• Construct a differential diagnosis
• Assess patients expectations and concerns
• Build rapport and develop the relationship
• Communicate diagnosis
• Negotiate management plan
• Support patient self-care
• Learn from the encounter by reviewing applicable
  diagnostic or therapeutic protocols.

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Health Maintenance Check-up

• Assess risk based on Family Hx, risk factors and
  prior preventive services for CA, CHD, ID,
  injury, metabolic and emotional health.
• Recommend/perform preventive services
• Assess patients expectations and concerns. Build
  rapport and develop the relationship
• Negotiate prevention plan and support self care.
• Learn by reviewing US Preventive Services Task
  Force Recommendations.

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Chronic Disease Follow-up

• Assess severity and control of condition
• Evaluate adherence and side effects of treatment
• Scan for target organ damage
• Review status of co-morbid conditions
• Assess patients expectations and concerns. Build
  rapport and develop the relationship.
• Assess patients learning needs.
• Renegotiate management plan support self-care.
• Learn from the encounter by reviewing relevant
  clinical guidelines.

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Psychosocial

• Assess emotional needs of patient or family
• Background
• Affect
• Trouble
• Handling
• Empathy
• Evaluate for diagnosable mental illness
• If depressed, evaluate suicide risk
• Assess patients expectations and concerns. Build
  rapport and develop the relationship.
• Negotiate follow-up
• Learn from the encounter by reviewing DSM IV
  criteria or other relevant resource.

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After you BATHE SPEAK

• Schedule each day
• Pleasant activity each day
• Exercise relaxation each day
• Assert yourself
• Kindness

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Behavior Change Visit

• Get background information on the problem
  behavior.
• Assess readiness to change
• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Relapse
• Assess patients expectations and concerns. Build
  rapport and develop the relationship.
• Set short and long term goals
• Negotiate next step
• Increase patients motivation to change
• Reflect on patients barriers and your own
  lifestyle.

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Leading Causes of Death in the United States in
2000
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Actual Causes of Death in the US in 2000
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NEWS FLASH

• Most visits are mixed visits!
• Remember to do your logs

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Teaching at the Bedsire Sir William Osler, MD,
1849-1919
It is more important to know that patient that
has the disease than which disease the patient
has.