LECTURE NOTES

IN FAMILY MEDICINE

Nandani de Silva
MBBS (Cey.), DCH, DFM, MD (Col.), FCGP (SL)

Senior Professor of Family Medicine

General Sir John Kotelawala Defence University
Professor Emeritus, University of Kelaniya
Sri Lanka

1
First Edition 2000
Second Edition 2006
Third Edition 2016

© Nandani de Silva

National Library of Sri Lanka-Cataloguing-In-Publication Data De

Silva, Nandani
Lecture Notes in Family Medicine/Nandani de Silva
Ratmalana: Sarvodaya Vishva Lekha, 2006 viii,188p.:
ill; 21c.m.
Second Edition
ISBN 955-599-469-
2
i. 610.7 DDC 22 ii. Title
1. Family medicine
2. Medical Science

All rights reserved. No part of this publication may be reproduced,

stored in a retrieval system, or transmitted in any form or by any
means, electronic, mechanical, photocopying, recording or otherwise
without the prior permission in writing of the copyright holder,
application for which should be addressed to the publisher.
 FOREWORD

I recommend this book to medical undergraduates and postgraduates

alike. Within these pages you will find lessons from a wise and
compassionate family doctor who has been a teacher of family
medicine for over thirty years.

Family medicine provides the opportunity to strengthen health

systems, improve the quality and safety of primary health care, and
support countries to move towards universal health coverage,
ensuring that every person, every family, every community, in every
nation, has access to health care services delivered by well trained
primary health care providers.

Many countries have developed strong systems of family medicine,

and Sri Lanka is no exception. Sri Lanka, with a population of
20,000,000, faces the dual serious health challenges of both
communicable and non-communicable diseases, along with the
challenge of an increasing population of elderly people, often with
multiple comorbidities and many needing home-based care. Sri
Lanka provides models for addressing these and other core health
challenges. I am told that the College of General Practitioners of Sri
Lanka’s motto is Arogya Parama Labha, that translates as, The
greatest of all gains is good health. The college has a strong and
well-established commitment to medical education, having worked
with the national Postgraduate Institute of Medicine to offer a
Diploma in Family Medicine, and an MD in Family Medicine for
those seeking specialist recognition. The College has also developed
the MCGP course and examination, accredited by the Sri Lanka
Medical Council in 2012 to meet the increasing demand for
postgraduate education in family medicine by doctors in both public
and private sectors. These developments among many others in Sri
Lanka continue to influence the development of family medicine
across the nations of South Asia, and around the world.

This textbook is another major contribution from Sri Lanka to the

global development of family medicine and I commend Professor
Nandani de Silva on this third edition with three new chapters and a
CD on topics of relevance to family medicine. Nandani has long
been an influential and respected medical and academic leader in Sri
Lanka. Being an active member of the Working Party on Education
from its inception in the World Organization of Family Doctors
(WONCA), she continues to play a significant role in global family
medicine education as well.

Professor Michael Kidd AM FAHMS

MBBSHons (Melbourne), MD (Monash), DCCH (Flinders), DipRACOG,
FRACGP, FACHI, FACNEM (Hon), FRCGP (Hon) United
Kingdom, FCGPSL (Hon) Sri Lanka, FRNZCGP (Hon) New Zealand,
FAFPM (Hon) Malaysia, FHKCFP (Hon) Hong Kong

President, Royal Australian College of General Practitioners, 2002-

2006
Professor of General Practice, The University of Sydney, Australia,
1995-2009
Executive Dean, Faculty of Medicine, Nursing and Health Sciences,
Flinders University, Australia, 2009-

President
World Organization of Family Doctors (WONCA)

Professor Michael Kidd AM

Executive Dean & Matthew Flinders Distinguished Professor
Faculty of Medicine, Nursing and Health Sciences
Flinders University

GPO Box 2100

Adelaide SA 5001
Australia
Tel: +61 8 8201 3909
Fax: +61 8 8201 3905
Mob: +61 414 573 065
Email: [email protected]

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 FOREWORD TO THE SECOND EDITION

The most noteworthy feature of family medicine that distinguishes it

from other disciplines is its emphasis on the process of care. From
the early sixties, family medicine educators have developed learning
experiences that enable students and doctors to understand the
process skills required, and to practise them in a supportive
environment.
Unlike a previous era when students, without prior instruction, were
told on their first clinical day “Go take a history from that patient”,
today they are introduced to a range of principles and techniques
long before being confronted by a real patient. Thus they bring to
their first consultation an understanding of the principles
underpinning the discipline, the process of the consultation, the
intricacies of the patient-doctor relationship, and the central
importance of patient-centred care. As the dialogue between the
patient and the doctor provides quite the most important information
for diagnosis and management, the physician skilled at establishing
rapport, listening thoughtfully to the patient’s complaints,
ascertaining precisely how the patient experiences the problem and
feels about it, determining the nature of the problem in all its
complexity, and then negotiating with the patient how it should be
tackled, will be in the best position to help the patient recover, or
adapt to the problem.

In writing Lecture Notes in Family Medicine, which focuses on the

process of care, Professor de Silva has done a great service to
medical students in Sri Lanka and the region, and with the second
edition has extended this to postgraduate students, who can use it to
build on the knowledge they gained in the undergraduate phase.
In addition to the consultation, the fundamental process in family
practice, the book deals with important related matters: clinical
decision making, counselling, breaking bad news, palliative care,
death and bereavement. Its focus on the critical importance of the
family in health and illness is laudable, as is the attention paid to
prevention and health promotion. Given the spectrum of illness in
the community, the increasing burden of chronic disease, and the
ageing of the population, anticipating and avoiding illness, and
promoting a healthy lifestyle is a vital activity. Referral, medical
records, and legal and ethical issues too are well covered.
This book is for all medical students, postgraduate trainees in family
medicine, and other health professionals who interact with those who
are ill. Trainees in other disciplines may be pleasantly surprised with
what it has to offer them.

Wesley E Fabb
AM, FRACGP, FCFPS (Hon), FFGP (SA) (Hon), MCFPC (Hon), FRCGP,
FHKCFP (Hon), FRNZCGP (Hon) FCGPSL (Hon), MSAAFP/PC (Hon)
Honorary Member AAFP, FAFPM (Hon)
Medical Editor, Global Family Doctor - Wonca Online, website of
the World Organization of Family Doctors
Chief Executive Officer, World Organization of Family Doctors
1981 -2001
 FOREWORD TO THE FIRST EDITION

It is a pleasure for me to write a foreword for Professor Nandani de

Silva’s book, especially because of my firm conviction that Family
Medicine has been, and always will be, a very important area of
medicine. The Faculty of Medicine, University of Kelaniya, is proud
to have one of the two pioneering departments of community and
family medicine in this country, and the subject is now well
entrenched in our undergraduate curriculum. It will only be a matter
of time till other medical faculties will have to follow this important
international trend in medical education.
One important problem that Sri Lankan undergraduates learning
Family Medicine face is lack of a text which is both informative and
of local relevance. In this context Lecture Notes in Family Medicine
will be very helpful, not only to our students, but also to medical
students of other faculties in Sri Lanka who receive no formal
instruction in this subject. The timing could not have been better, for
we are entering a period where there is a high probability that large
numbers of newly passed out doctors will take up family practice.
The book is based on a series of undergraduate lectures given by the
author and covers the subject admirably. Starting from a simple
introduction and principles of family medicine it takes the reader
through the doctor-patient relationship, and the family medicine
contexts of clinical methods, patient management, health promotion
and care of the patients’ family. It also tackles important issues such
as care of the elderly, terminal illness and bereavement, ethical and
legal issues in family practice and that important, but often neglected
area, maintaining good medical records. In other words it gives
students good instruction on a holistic approach to patient care in
family practice.

I am honoured that the author has asked me to write this foreword,

and I have no hesitation in recommending this book to all medical
students, and even to doctors starting out as family physicians, as a
very reliable guide to Family Medicine.

Professor H. J. de Silva
Dean,
Faculty of Medicine
University of Kelaniya

PREFACE

Twelve Lectures in Family Medicine were included in the formal

undergraduate curriculum with the establishment of the Department
of Community and Family Medicine in 1994 at the Faculty of
Medicine, University of Kelaniya. Having pioneered the
undergraduate Family Medicine programme in this medical school, I
designed the lectures to include only the concepts, principles and
process of family medicine that demonstrate the uniqueness of this
new discipline, leaving the vast clinical content to be covered during
family practice attachments.
I wrote my first book on ‘Lecture Notes in Family Medicine’ in the
year 2000. The first book was written purely for medical students
whom I found had difficulty in understanding family medicine
textbooks used by students in Western countries. Hence the need for
a book written in an easily understood and reader friendly manner to
guide medical students whose mother tongue is not English, to
understand and learn family medicine. After this first book was
published, I found that there was a demand for the book by
postgraduate trainees as well as many other doctors. This made me
embark on a second edition by the addition of new material
comprising 16 chapters which could also cater to family medicine
learners at a higher level of learning.
After retirement from the University of Kelaniya in 2009 and
conferment of the title of Emeritus Professor, I embarked on
conducting continuing medical education (CME) online courses at
the Open University of Sri Lanka during my tenure as its Vice
Chancellor from 2006 to 2009. I also continued to teach
postgraduates following the MCGP Diploma course being conducted
by the College of General Practitioners of Sri Lanka. In 2014, I
renewed my interest in undergraduate teaching by joining the Sir
John Kotelawala Defence University as Senior Professor of Family
Medicine within a joint department of Public Health and Family
Medicine. Since there was a demand for the book among medical
students and doctors, I decided to publish a third edition of ‘Lecture
Notes in Family Medicine’. Many of the chapters have been updated
in this third edition of the book which also includes three new
chapters and a CD of a narrated powerpoint presentation on Clinical
audit. The CD and the last new chapter on Qualitative Research in
Medicine was added as these are two areas of considerable
importance to academic Family Medicine not usually covered in
medical textbooks. The other extra chapters comprise the detection
and management of the somatizing patient and the consultation with
small children and their parents which again are areas that require
special attention of not only family physicians but all those working
at the level of primary care medicine.
As with the second edition, the third edition of ‘Lecture notes in
Family Medicine’ does not include the clinical content of family
medicine but encompasses the principles and practice of family
medicine and other relevant topics. Medical schools that have
changed the curriculum to include a behavioural science strand may
find this book useful as it includes topics such as illness behaviour,
doctor- patient relationship, ethical aspects in medical practice,
breaking bad news, bereavement care and skills of communication
and counselling. This book should also be useful to all doctors to
develop the skills and attitudes necessary to provide person centred
care, which becomes important and relevant when practicing in
ambulatory care settings.

I hope that this book will help medical students and postgraduates
understand and acquire knowledge of family medicine as a distinct
discipline and also motivate them towards a career in family
medicine.
Nandani de Silva
May, 2016
 ACKNOWLEDGEMENTS

I am really honuored and privileged that Professor Michael Kidd

agreed to write the Foreword for this book in the midst of his
extremely busy schedule and immense commitments, being the
President of WONCA, the World Organization of Family Doctors. I
have known Michael over the past twenty years and we have met at
several WONCA conferences. He was the external examiner for the
MD Family examination at the Postgraduate Institute of Medicine
while I was the Chief Examiner and it has been a pleasure working
with him and learning from him. He is also an Honorary Fellow of
the College of General Practitioners of Sri Lanka and was present
this year too as the Chief Guest at the WONCA South Asian
Regional Conference.
 CONTENTS

1. Introduction to Family Medicine

2. Principles of Family Medicine
3. The Consultation and Doctor-Patient Relationship
4. The Process of Care in General Practice and Hospital Settings
5. Clinical Decision Making in Family Practice
6. Patient Management in Family Practice
7. Referral in Family Practice
8. Health Promotion and Disease Prevention
9. Illness in the Community & Profile/Content of Family Practice
10. The Focus on ‘Family’ in Family Practice
11. Detection and Management of the Somatizing Patient
12. Counselling and Supportive Psychotherapy
13. The Consultation with Sick children and Parents
14. Care of the Elderly
15. House calls and Home Care
16. Breaking bad news, Palliative Care, the Dying Patient and
Bereavement
17. Medical Records in Family Practice
18. Ethical and Legal Issues in Family Practice
19. Qualitative Research in Medicine
20. Clinical Audit in Family Practice
21. References
22. Index
Chapter 1
 INTRODUCTION TO FAMILY MEDICINE

The World organization of National Colleges, Academies and

Academic Associations of General Practitioners/Family Physicians
(WONCA) was established in 1972. This organization also referred
to as the World Organization of Family Doctors, has 118 member
organizations and 21 departments in the academic membership
category from 131 countries representing more than 500,000 family
doctors worldwide. Around 800 family doctors are direct members
of WONCA in the individual membership category.

The mission of WONCA is to improve the quality of life of the

peoples of the world by promoting values and maintaining high
standards of care in General Practice / Family Medicine. Family
Medicine / General practice are terms used by WONCA to describe
the care given by Family Physicians / General Practitioners to
individuals in the context of the family and the community. Taking
into account that the nomenclature used to describe family medicine
varies in different parts of the world, this book will use the terms
family medicine / general practice / primary care medicine
interchangeably throughout this book as they refer to the same
medical specialty with the same principles that distinguishes it from
all other medical specialties.
The recognition of family medicine as an academic discipline began
in the UK in 1952, when the Royal College of General Practitioners
recommended that every medical school should have a department of
general practice. In the University of Edinburgh, Richard Scott was
appointed to the first chair in general practice in the world in 1963.
In the USA, the terms family medicine and family practice were used
in place of general practice to emphasize family oriented care, which
helped the discipline to gain academic acceptance within the medical
fraternity. Thus in 1969, family medicine was accepted as the 20th
clinical discipline in the USA. Since then, medical schools in many
parts of the world have established departments of Family Medicine /
General Practice, either as independent departments or as joint
departments of Community Medicine and Family Medicine.
Sri Lanka was one of the first countries in the South Asian region to
take the initiative of giving medical students an exposure to general
practice. The first students to benefit from this experience were
fourth year students from the Faculty of Medicine, Colombo in 1984.
The first departments of Family Medicine were set up in the
Faculties of Medicine of the Universities of Kelaniya and Sri
Jayawardenepura, as joint departments of Community and Family
Medicine in 1994. The other universities in Sri Lanka have not yet
given separate departmental status to family medicine.
Some universities in other South Asian countries have also included
the teaching of family medicine to undergraduates to varying extents
with a few having established Departments of Family Medicine eg.
the Aga Khan University in Pakistan and BP Koirala Institute of
Health Sciences in Nepal.

Why is it important to teach family medicine to medical

students?

To improve employability of medical graduates

The need to teach family medicine to medical students is more
important now, than ever before. In Sri Lanka, since the late 1990s,
more than 1000 medical graduates have been qualifying each year
from the eight state medical schools. To this number, around 50 more
per year needs to be added, taking into account the military medical
graduates passing out from the newest medical school in Sri Lanka at
the General Sir John Kotelawala Defence University in Ratmalana.
This is the youngest medical school to be established in a state
university and the first under the Ministry of Defence, all other state
medical schools coming under the Ministry of Higher Education.

It is anticipated that the state health services may not be able to

employ all doctors who qualify within the next few years. It is
obvious that many of those who do not get employed by the state
health services will have to set up as general practitioners / family
physicians in the private sector. Many of the doctors qualifying in
increasing numbers from other countries in South Asia are also
expected to become general / family practitioners. Therefore it is
very important that medical students should receive education and
training in family medicine.

To learn about illness prevalent in the community

It is also important to teach family medicine to medical students, so
that they will learn about the illnesses that are prevalent in the
community and affecting about 90% of the sick people in a
population at any one time. This was aptly illustrated in a survey
carried out in the USA and Great Britain, on illness in the
community and utilization of medical care by Kerr White et al in
1961. (Fig. 1) The survey found that among 1000 persons over the
age of 16 years in a given month, 750 suffered symptoms. Of the 750
who suffered from symptoms, 500 practised self care while only 250
consulted a doctor. Of the 250 who sought professional medical
advice, 235 consulted a family physician / primary care physician, 9
were admitted to a general hospital, 5 sought specialist advice and
only one was admitted to a teaching hospital where medical students
undergo most of their training.

A similar study on health care utilization repeated in 2001 by Larry

Green et al. in the USA shows almost the same findings (Fig.2). This
study found that for every 1000 men, women and children in the
USA, 800 experience symptoms, 327 consider seeking medical care,
217 visit a physician in the office ( 1 1 3 visit a primary care
physician and 104 visit other specialists), 65 visit an alternative care
provider, 21 visit an out patient clinic, 14 receive home care, 13
receive emergency care, 8 are hospitalized and less than 1 is
admitted to an academic medical center. This means that although
changes have taken place in the organization and financing of health
care, the utilization of medical care has not changed much over 40
years.
Prevalence of illness and utilization of medical resources among
1,000 adults in the United States and Great Britain. (From White
et al 1961)
Fig. 2
Results of a re­analysis of the monthly prevalence of illness in the 
community and the roles of various sources of health care. Each box 
represents a subgroup of the largest box, which comprises 1000 persons. 
Data are for persons of all ages. 

( Reference; Larry A Green et al. The Ecology of medical care revisited. N 
Eng J Med, Vol,344, No.26, 2001. Copyright 2001 Massachusetts Medical 
Society) Reprinted with permission from Massachusetts Medical Society,  

In summary, the study shows that more men, women and children
receive medical care in primary care physicians’ offices than in any
other professional setting, which means that the bulk of health care
remains in primary care and ambulatory care. It is also apparent from
these two surveys, that teaching hospitals where medical students
receive most of their training, are providing medical care to only one
person out of more than 300 persons seeking medical care at any one
time.
In Sri Lanka, the Annual Health Bulletin 2013 published by the
Ministry of Health reports, that within the preceding 5 years, the
number of “in” patients ie those who had been admitted to
government hospitals amounted to five million while 50 million had
attended “out” patient departments of government hospitals each
year. In the year 2013, 289 per 1000 population had been admitted
to government hospitals while 2629.5 per 1000 population had
sought out patient care. This shows on the average, at least two visits
per person to an out patient department of a government hospital that
year. In addition, private general practices in Sri Lanka have been
estimated to deal with at least 12.7 million consultations per year (de
Silva and Mendis, 1998). The above statistics show that the majority
of sick people in the population are suffering from common illnesses
which do not require admission to hospital. Therefore, medical
students should learn how to manage these illnesses in the
community that most doctors would encounter during their
professional life.

While the majority of illnesses seen at the primary care level are
common illnesses which are sometimes minor and self limiting, there
are also patients in the early stages of serious illnesses, patients with
non communicable diseases needing long term care and patients with
psychosocial problems. Doctors need special knowledge and skills to
manage these common problems, many of which are never seen in a
hospital setting, because they do not require the skills of a hospital
consultant nor the technology contained in a teaching hospital. Thus,
medical students should learn the wide range of illnesses that affect
most of the people most of the time. Such teaching and learning
could ideally take place in a family practice setting in the
community.

To learn the humanistic approach to patient care

Whatever the discipline students decide to specialise in, they must
learn that humanism, compassion and concern for the patient is basic
to all medical care. The family physician, who provides a
personalised type of care to patients and their families within the
context of a good doctor-patient relationship, is ideally placed to
teach students, the compassionate approach to patient care.
As Francis Peabody stated in 1923, “One of the essential qualities of
the clinician is interest in humanity, for the secret of the care of the
patient is in caring for the patient”

Family medicine in the health care system

In the conceptual model of a health care system shown in Fig. 3,
forming the base is the level of self care. The next level of care is
primary care followed by secondary care and tertiary care. Each
level of care serves different sizes of the population and is managed
by different categories of persons and health professionals.
When persons in the community experience symptoms or feel ill,
they will treat themselves with home remedies or medicines such as
paracetamol for a headache and so on. This is called self care, where
the patient and the family undertake to treat minor ailments at home.
Some may resort to over the counter (OTC) medication. In such
instances the patient requests the pharmacist for a drug to cure fever,
a skin rash, sore throat, abdominal pain etc.
If the patient does not get better with self treatment, he or she will
seek professional advice and will consult a medical practitioner at
the next level of care, which is primary care. This is also called first
contact care, because this is the first point of contact a patient has
with a doctor in the health care system.
In Sri Lanka, at the primary level of care are western qualified
MBBS doctors who are medical officers in outpatient departments of
state or private hospitals and general practitioners / family physicians
in the private sector. There are also categories of medical
practitioners referred to as assistant medical officers (AMOs) and
registered medical officers (RMOs) who have undergone a limited
period of training culminating in a Diploma, which entitles them to
practice medicine at the primary care level. In addition, there are
practitioners of alternative and complementary systems of medicine
such as Ayurvedic physicians, acupuncturists, homeopaths and
traditional healers practising at the level of primary care. All
practitioners at the level of primary care will serve the people in the
locality around their practices.
 Fig. 3 Levels of health care (Adapted from Fry, 1978)
Patients who have serious diseases that need specialised care and
those who do not get better with treatment at the level of primary
care, are cared for at the next level, which is secondary care.

At the level of secondary care are general specialists such as

physicians, surgeons, obstetricians and paediatricians who practice
from hospitals that serve an entire district or districts.

Tertiary care is the care given by sub-specialists such as

neurosurgeons, cardiologists, neurologists and ophthalmologists.
They deliver a highly specialised type of care from teaching
hospitals or specialised hospitals and will have patients referred to
them from one or more states or provinces. Therefore the higher the
level of care, the larger will be the population it has to serve. In
countries where there is no enforced referral system, patients could
by pass the levels of primary care and secondary care and go directly
to the tertiary care level.
 Chapter 2

PRINCIPLES OF FAMILY MEDICINE

Definition of Family Practice

The American Academy of Family Physicians (AAFP) and the
American Board of Family Practice (ABFP) have defined Family
Practice as “....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.”

What is Family Medicine ?

Family medicine is the discipline on which family practice is based.
Family medicine describes the body of knowledge, skills and
attitudes that are necessary for family physicians to deal with
problems brought to them by patients and their families.
Family medicine is a speciality in breadth and not one in depth. It is
a speciality in breadth because it requires a wide knowledge of
several other clinical disciplines such as Medicine, Surgery,
Obstetrics & Gynaecology, Paediatrics, Psychiatry, ENT and
Dermatology without going into depth in any single speciality.
Family physicians are generalists, who will have knowledge of the
common illnesses within any clinical discipline, that are prevalent in
the community and rarely seen in hospital. Most of the time, family
physicians will use their clinical acumen in diagnosis using minimal
investigations. They will assess the illness in physical, psychological
and social terms and adopt a holistic approach to the management of
their patients.
Because of the wide knowledge of all the clinical disciplines, the
family physician will be able to identify a patient who needs
specialised care by a specialist in a particular field. For example,
when a patient presents with a red eye, the family physician will
decide whether the patient has only a conjunctivitis which could be
treated at the level of primary care or whether the patient is suffering
from acute glaucoma which needs referral to an opthalmologist.
Thus, specialists will see patients selected for them by generalists.
Specialists who have an extensive knowledge of their discipline in
depth, will use their expertise and high technology investigations to
diagnose the more serious and rare variants of diseases within their
speciality. They will treat patients in a hospital setting using
advanced therapeutic procedures.
In addition to a wide knowledge of other clinical disciplines, family
medicine also requires a knowledge of the behavioural sciences eg.
sick role and illness behaviour, doctor-patient relationship, how a
family functions in health, influence of the family on illness and
illness on the family, effects of bereavement etc.
Skills in family medicine include communication skills and
counselling skills, problem solving skills of the undifferentiated
illness and 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.
Finally, family medicine requires an attitude that respects the patient
as a person who needs help, and not as a disease that has to be cured.
As Sir William Osier 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”

Definition of a Family Physician

‘Family physicians provide health care to individuals within the
context of the family and community irrespective of race, culture or
social class. Family physicians are able to manage most problems
brought to them, whether physical, psychological or social,
regardless of age, sex or nature of the presenting complaint. Their
training has given them a unique set of knowledge, skills and
attitudes which qualify them to provide first contact care and
comprehensive medical care to the entire family. Family physicians
undertake the responsibility of providing continuing and patient-
centred care to patients and help in coordinating their health care
through the appropriate use of consultants and community
resources’.
The above definition of a Family Physician which describes what a
family physician actually does in practice, was developed using a
combination of the one used by the American Academy of Family
Physicians (AAFP) and the one given in the latest guidebook of the
World Organization of Family Doctors titled ‘The contribution of
Family Medicine to Improving Health Systems’ 2013.
The following are the principles of family medicine which govern
the roles and functions of the family physician.

Principles of family medicine

Family physicians should ideally
* Live in the community in which they practice and be
accessible and available to their patients.
* Have a commitment to the patient as a person who needs
help, irrespective of age, sex or nature of the problem.
* Understand the context of a patient’s illness.
* Consider the patient as the continuum and the episode as the
disease.
* Have an insight into relationships with patients and be aware
that a doctor’s attitudes, values and feelings are important
determinants in the practice of medicine.
* See patients in the office, home or hospital.
* See the practice as a population at risk and have a
commitment to maintain the health of patients.
* Consider every consultation as an opportunity for prevention
of disease and promotion of health.
* Be the centre of a network of health resources in the
community and the hospital and be the manager of such
resources

Roles and Functions of the Family Physician - The roles of the

family physician exemplify the generalist function of the family
physician / primary care physician and describes the different types
of care that Family Physicians provide. The integration of the
different types of care into clinical care at the primary care level has
been shown to result in improved health outcomes.

1. First contact care

2. Patient- centred care and family care
3. Continuity of care
4. Comprehensive care
5. Preventive care
6. Coordination of care

First contact care - Family physicians function as doctors of first

contact because they are practising at the level of primary care in the
community. To function as doctors of first contact, they have to be
accessible and available to their patients. Therefore ideally, family
physicians should live in the community in which they practise. By
living in the same community as their patients, they will also have a
first hand knowledge of the health problems in the community. As
doctors of first contact, family physicians deal with patients of either
sex and any age, irrespective of the nature of the presenting
complaint.
Family physicians also work in less than ideal circumstances with
minimum facilities. They have to make an initial assessment of the
problem in every case, whether it is a medical or surgical problem or
a psychological or social problem.
Family physicians have to be competent clinicians, as patients
consult with early undifferentiated illnesses, when symptoms are
vague and signs are minimal. After making an initial assessment of
the problem, a decision is made whether to manage the patient at the
primary care level, and this is what happens most often. On the other
hand, a decision may be made to refer the patient to a higher level of
care or other health facility in the community. When instituting
management, the family physician would respect the autonomy of
the patient and negotiate a cost effective management plan to suit
each individual patient.
Patient-centred/personalised care and family care - The family
physician provides patient-centred or personalised care to patients
and their families. The family physician thinks not in terms of
disease but in terms of patients who have problems needing
attention. The family physician is able to deliver personalised care,
because of the close and personal relationship that exists between the
doctor and the patient and family over a long period of time. The
family physician knows the patients in their own environment. The
family physician is not only the patient’s physician but the family
friend, who will try to understand the context of the patient’s illness.
The doctor will listen with concern and empathy and understand the
personal, family and psychosocial factors that intertwine with the
patient’s disease. The family physician will explain to patients and
their families the nature of the illness, its causes and implications.
The doctor will act as advisor to patients and guide them through the
maze of specialist care and high technology hospital care when
necessary.
Family physicians get a rich and rewarding experience with
humanity and satisfaction from family practice, due to the personal
commitment they have towards their patients.
Continuity of care - The family physician gives continuity of care by
caring for patients and their families over a time span of many years.
The family physician considers the patient as the continuum of care
and the episode as the disease, unlike in a hospital setting where the
disease is the continuum and the episode is the patient.
The family physician cares for members of different generations of a
family from before birth till after death. For example, the family
physician may simultaneously provide prenatal care to a pregnant
woman and care for her grandmother’s depression, following the
death of the grandfather whom the doctor had treated for a stroke.
Continuity of care is therefore described as care provided from the
womb to the tomb or from the cradle to the grave.
Continuity of care could be considered at three levels, longitudinal,
interpersonal and informational.
Longitudinal continuity of care means that the doctor undertakes the
responsibility of seeing any problem through to its conclusion. A
minor illness will be treated by the doctor in the family practice
setting while a more serious disease may require admission to
hospital for specialized care. The doctor may communicate with the
specialist and follow up the patient in hospital. Once the patient is
sent home, the family doctor will provide follow up care until the
patient recovers from the illness. If the disease cannot be cured, the
doctor would help with rehabilitation and offer comfort and relief
and care for the patient until death. When the patient dies, the doctor
would help the bereaved family cope with their grief and offer
psychological support.
Interpersonal continuity of care is an extension of longitudinal
continuity of care where the family physician has an ongoing
responsibility for the welfare of the patient based on trust within a
strong doctor-patient relationship. When interpersonal continuity
exists, the patient’s personality, family background, cultural beliefs
and reactions to illness are stored in the doctor’s memory to be
recalled whenever the patient enters the consulting room. This
enables the doctor to observe and monitor changes in the symptoms
of a medical problem or the results of treatment over time using the
“watchful waiting technique’. Utilization of this technique by the
family doctor who has previous knowledge of the patient could avoid
the use of expensive investigations to help in diagnosis, unlike a
specialist who may be seeing the patient for the first time. A study in
the U.S.A. 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.
Therefore, interpersonal continuity of care is more cost effective
while offering opportunities for preventive care as well.
Interpersonal continuity of care also enhances physician patient
satisfaction as it allows the doctor 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.

Informational continuity refers to the collection and use of medical

information or patient data that is accessible when required to the
patient’s own family doctor or to any other doctor who is acting for
the regular family physician. Informational continuity where the
details of the patient’s health problems over a long period of time are
documented is important to ensure high quality patient care in
clinical practice. This means that the family physician has to
maintain medical records where the patient’s present and past
medical problems, results of investigations, medication prescribed,
family history and social circumstances are documented in a format
that is easily retrievable. The medical records could be maintained as
paper based records with easy storage and retrieval processes in
place or as electronic records with the doctor having mastered the
necessary technical skills. See more details about Medical Records in
Chapter 17.
Continuity of care overall has been found to lead to better
compliance with treatment regimens, higher patient-physician
satisfaction and improved health outcomes.

Comprehensive care - The family physician provides total health

care or holistic care to patients. Holistic care means attention to the
person, the problem and the total living environment.

Comprehensive care means making an assessment of the patient’s

problem in physical, psychological and social terms and managing
the patient as an individual in the family and community, using both
curative and preventive measures.

Fig. 1 The three faces of comprehensive care

(Adaptedfrom: Medalie, JH(ed). Family Medicine Principles and Applications.
Baltimore, Williams & Wilkins, 1978, p. 18)
For the family physician to assess the problem in physical,
psychological and social terms, a wide knowledge of all the clinical
disciplines as well as awareness of the illnesses that are prevalent in
the community would be necessary. The doctor knows that the
illnesses which are prevalent in the community are the common and
minor illnesses which are sometimes self limiting, serious diseases in
the early stages and chronic diseases (non communicable diseases)
where long term care is needed. Because family physicians know
their patients well, they will see the social, psychological, personal
and family factors that intertwine with disease. After taking into
consideration all these influences that play a part in the patient’s
illness, the family physician will make an initial assessment of the
patient’s problem in physical, psychological and social terms.
When planning management, the doctor has to treat the patient as an
individual in the family and community. In managing the patient, the
patient’s religious and cultural beliefs, fears, expectations and
interpretations of the illness, socioeconomic status and health
facilities available in the community have to be considered. The
patient is then managed within these constraints in a manner that is
convenient and cost effective for the patient.

In the actual medical part of the management, the family physician

will combine both curative and preventive measures. Curative
measures will involve advice, medication, minor surgery etc.
Preventive care will involve prevention at all three levels primary,
secondary and tertiary.

Preventive care The family physician is ideally placed to practise

preventive care and promote the health of his or her patients.
Preventive care could be delivered at three levels, primary,
secondary and tertiary. Primary prevention refers to any action taken
to avoid or remove the cause of a health problem in an individual or
community before it arises. For example, 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.

Secondary prevention refers to action taken to detect an illness or

health problem at an early stage where early diagnosis and treatment
can help to cure eg. anaemia in a pregnant mother. Tertiary
prevention is action taken to reduce the functional; impairment
consequent to an acute or chronic health problem eg. in a patient
with a chronic illness such as a hemiplegia, further disability can be
prevented by making arrangements for the patient to have
physiotherapy.

The family physician 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. For example, the doctor may check the
BP in a middle aged patient who consults for some other problem
and detect asymptomatic hypertension which if adequately
controlled, could prevent complications or premature death occurring
in the future.

Family physicians also practise anticipatory guidance and preventive

counselling. By having a knowledge of the stressors that occur at the
different stages of the family life cycle, the family physician could
anticipate problems before they arise and give preventive
counselling.

Coordination of care - Family physicians have an important role to

play in making use of all health care resources in the hospital or in
the community for the benefit of their patients. Although the family
physician’s clinical skills and 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 family physician must have a broad

knowledge of the patient and his or her problem, the family, the
nature and severity of the illness, the patient’s fears, expectations and
reaction to illness 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
such as the Medical Officer of Health (MOH) and non governmental
organisations (NGOs). 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.

All the above functions of the family physician are exemplified in

the portrait of a “five star doctor” described by Charles Boelen
(WHO 1994). He states that in a health service using an integrated
approach and based on people’s needs, the “five star doctor” portrays
a symbol of excellence by displaying five basic sets of attributes as
listed below.

Profile of a “five-star doctor”

Adapted from Charles Boelen, WHO 1994
* Care provider, who considers the patient holistically as an
individual and as an integral part of a family and the
community, and provides high quality, comprehensive,
continuous and personalised care within a long term relationship
based on trust.

* Decision maker, who chooses which technologies to apply

ethically and cost-effectively while enhancing the care he or she
provides.

* Communicator, who is able to promote healthy lifestyles by

effective explanation and advocacy, thereby empowering
individuals and groups to enhance and protect their health.

* Community leader, who, having won the trust of the people

among whom he or she works, can reconcile individual and
 community health requirements and initiate action on behalf of
the community.

* Manager, who can work harmoniously with individuals and

organizations inside and outside the health system to meet the
needs of patients and communities, making appropriate use of
available health data.

The “five star doctor” is ideally suited to work in a health service

based on people’s needs and based on an integrated approach that
embodies the values of quality, equity, relevance and cost
effectiveness.

Chapter 3

THE CONSULTATION AND

DOCTOR - PATIENT RELATIONSHIP

The consultation
“The essential unit of medical practice is the occasion on which, in
the intimacy of the consulting room or sick room, a person who is ill
or believes himself to be ill seeks the advice of a doctor whom he
trusts. This is a consultation and all else in the practice of medicine
derives from it”
Sir James Spence 1960
The intimacy or privacy of the consultation room gives the patient
the opportunity of divulging personal aspects of the problem to the
doctor with the hope that such disclosure will help in the diagnosis of
the illness. In placing his or her trust in the doctor, the patient
expects the doctor to maintain professional secrecy or
confidentiality. This means that the patient expects the doctor not to
divulge anything revealed during the consultation to anyone else
without the patient’s permission.

Within the atmosphere of mutual trust that prevails during a

consultation, the patient believes that the doctor will help him or her
to get over the illness while the doctor expects the patient to
cooperate as fully as possible with the treatment given.

Various models of the consultation have been proposed from time to

time, each emphasizing a slightly different aspect which needs
attention during an ideal consultation.

Michael Balint (1957) identified the somatisers who used a physical

complaint as a “ticket of entry” into the consulting room when the
actual problem was a psychological disturbance. Balint encouraged
general practitioners to teach such patients about more appropriate
consulting behaviours.

Stott and Davies (1979) who described the potential of a primary

care consultation also acknowledged that modification of help
seeking behaviour was important in addition to the management of
presenting problems, management of continuing problems and
attention to opportunistic health promotion. (Fig. 1)

A B
Management of
presenting problems Modification of
help-seeking
behaviours

C D
Management of Opportunistic
health promotion
 continuing problems

Fig. 1. The potential of a primary care consultation

(Stott and Davies 1979)

The model of a consultation proposed by Pendleton and colleagues

(1984) identifies seven tasks which need attention during an ideal
consultation.

Pendelton’s model of an ideal consultation

The first task
To define the reason for the patient’s attendance, including:
1. The nature and history of the problems
2. Their aetiology
3. The patient’s ideas, concerns and expectations
4. The effects of the problems
The second task
To consider other problems:
1. Continuing problems
2. At-risk factors

The third task

With the patient choose an appropriate action for each problem
The fourth task
To achieve a shared understanding of the problems with the patient.
The fifth task
To involve the patient in the management and encourage the patient
to accept appropriate responsibility
The sixth task
To use time and resources appropriately:
1. In the consultation;
2. In the long term
The seventh task
To establish or maintain a relationship with the patient which helps
to achieve the other tasks.

Pendelton and others suggest that it is not necessary to follow the

tasks in the same order nor attend to all the tasks at every
consultation. The first five tasks are separate statements of what the
doctor needs to achieve. The final two tasks of using time and
resources effectively and creation of an effective doctor-patient
relationship relate to the consultation as a whole and help in the
achievement of all the previous tasks.
The model of a consultation described by Roger Neighbour (1987)
identifies five steps in the consultation.

Neighbour (1987)

1. Connecting with the patient

2. Summarising the problem
3. Handing over responsibility for management
4. Safety-netting
5. Housekeeping
The first three tasks are similar to those in previous consultation
models. Safety-netting means that the doctor would safety-net by
explaining to the patient the following:-

* The possible causes for the symptoms

* Other symptoms which may lead to a change in the order of
diagnostic probabilities
* The possible complications that could occur

In the event of such changes in the condition, the doctor would

advice the patient to come for review and further management.
‘Housekeeping’ emphasizes that doctors too need rest to sustain their
own physical and mental energy and should schedule their
appointments and list size to prevent exhaustion at the end of a
working day. This would enable the doctor to function at optimal
performance and thereby give their best to the patients.
Effectiveness of the consultation
An effective consultation is one which achieves desired outcomes.
The outcomes of a consultation described by Pendleton and
colleagues (1984) should ideally be as follows:-

Immediate outcome - a change for the better in the patient’s

ideas and concerns
- patient feels reassured and understands
the problem
- patient agrees to adhere to a
management plan
- patient is satisfied with the consultation

Intermediate outcome - compliance with the management plan

and recovering from the illness
Long-term outcome - Change for the better in the patient’s health
- Improvements in the patient’s health
understanding

Time for the consultation

The family physician is able to use time efficiently because of
previous knowledge of the patient from a long standing doctor-
patient relationship. The doctor would also have the patient’s
medical record, with the list of problems and illnesses the patient has
suffered from in the past, which is useful in arriving at a quick
assessment of the patient’s problem.

It has been found that the ideal time for a general practice
consultation is 10 minutes although experimental studies have found
the actual time to vary between 1 - 29 minutes. Time needs to be
used appropriately and a longer consultation may reduce the need for
future consultations. Conversely, a shorter consultation may allow
time for more information to become available such as new
symptoms or signs or the results of investigations. Time spent during
a consultation could be analyzed from many viewpoints and is
influenced by a number of factors:
 * Waiting time to see the doctor
* List size
* Appointment systems
* Doctor’s communication skills
* Patient expectation of explanation and reassurance
* Difficult and demanding patients
* Attention to psychosocial issues
* Attention to health promotion
* Use of clinical guidelines and evidence based medicine
* Use of paper based or computerized medical records
* Prescribing patterns
* Doctor’s income
* Patient satisfaction
* Doctor ‘s stress levels and satisfaction
* Quality of the doctor-patient interaction
* Patients’ health outcomes
Time is an element that would finally determine whether the doctor
does all the right things and does everything right so as to bring
about patient satisfaction and a health outcome that would improve
the patient’s quality of life.

Doctor-patient relationship
The clinical process of the consultation takes place within the
context of the doctor-patient relationship. The doctor-patient
relationship built up over the first consultation goes on over many
years of continuity of care. The doctor and the patient get to know
each other over a long period of time. In most instances the doctor
would also have a similar relationship with other members of the
patient’s family.

The doctor patient relationship is made up of two elements, one is

rapport which is an emotional element and the other is
communication which is an intellectual element. Both of these are
two way exchanges.

Rapport is an emotional element which depends on how the doctor

greets the patient and the interest the doctor shows in the patient. The
welcome and interest the doctor shows in the patient which is
distinct from that shown to the patient who came before or the one
due to come after, is important by its uniqueness for each patient.

Rapport established at the first consultation, gets strengthened at

every subsequent consultation over many years of continuity of care.

Rapport is a two way process and the role played by doctor and
patient are equally important. There are a few patients who are
naturally reserved or withdrawn and are unable to form a relationship
at the beginning. However, over a period of time this would improve,
once the doctor and patient get to know each other.

Communication is an intellectual element which depends on whether

the doctor and patient understand each other. The doctor should be
able to understand the whole of the patient’s communication. In
order to do this the doctor needs to give his or her full attention to
the patient seated before him or her by leaving aside the doctor’s
own personal problems and by letting go all concerns about the
patient who came before. This leads to the generation of a positive
therapeutic alliance between the doctor and patient that is necessary
for a successful doctor-patient relationship.
For communication to be effective, the doctor and patient should
preferably speak the same language. Also the doctor should not use
medical terms that the patient may not understand.
The skills of conducting a medical interview are outlined below;
1. Active listening - The doctor should listen with concern to the
patient and allow the patient to express himself or herself
freely, prompting the patient now and then by “mm” and “ah”
sounds and by gestures such as nodding of the head etc. The
doctor should refrain from interrupting the patient. Listening
without interrupting for a minimum of one to two minutes will
elicit a lot of useful information from the patient.
2. Facilitation where the doctor prompts the patient is also a
useful interviewing skill. The doctor could say “ yes, go on,
tell me more about it”.
3. Reflecting back to the patient what patient has said shows the
patient that you are paying attention to what he or she is
saying.
4. Clarification is where the doctor wants to make sure he or she
has understood what the patient is trying to convey. For
example, the doctor could say, “what to do you mean you have
arthritis ? can you elaborate a little on that?”
5. Asking questions - When the time comes to ask questions, the
doctor should ask only a few direct questions, because direct
questions will receive only direct answers such as ‘yes’ or ‘no’
and the doctor will hardly get to know anything else.
Open ended questions should be asked first to understand the
patient’s whole communication ie. his fears, concerns and
expectations. For instance the doctor could ask open ended
questions - such as “ Could you tell me more about your
headache” or “it seems to me that you are unhappy”. Such
statements by the doctor, may result in the patient telling the
doctor the real reason for coming, thereby revealing the
background to the illness.

Closed or specific questioning should be left until later when

the doctor wants to narrow down the diagnosis.

6. Body language and non verbal cues - the doctor should observe
the patient for non verbal cues, to understand what the patient
is communicating through his or her behaviour. Non verbal
cues could vary from the patient’s appearance and the way in
which the patient walks into the consulting room, to fidgety
hands, a wrinkled brow or tears in the eyes. The doctor’s body
language such as good eye contact and leaning towards the
patient to show more attention, are important to make the
patient feel that the doctor is genuinely interested in the
patient’s welfare.

7. Empathy - It is important to convey empathy to the patient.

This involves using a sympathetic approach, where the doctor
listens with concern and shows the patient that the doctor
understands the patient’s feelings about what is happening to
him or her. Empathy could be conveyed both verbally and non
verbally. Eg. The doctor could say “I can understand how you
feel” or “you must be going through terrible pain” while
maintaining eye contact and a tone of voice showing concern.
 Empathy will help in eliciting family and psychosocial factors
relevant to the patient’s illness.

Empathy is not only an emotion evoked in the doctor. It is also

an important tool in the doctor-patient relationship which can
be used by the doctor for diagnostic and therapeutic purposes.
By being empathic and asking an open ended question, the
doctor can get much diagnostic information from the patient.
Depressed patients may even burst into tears and reveal all their
feelings and problems to the doctor. Listening to the patient
with empathy also has a therapeutic effect. Patients get better
after having talked to the doctor and having ventilated their
feelings. As Michael Balint stated, the doctor is the most
frequently used ‘drug’ in general practice.

8. Silence - There are times during the consultation where

maintaining silence is useful. However, the doctor should
continue to show interest by maintaining an appropriate posture
and a facial expression of concern. Although difficult in
practice, the doctor should learn the skill of remaining silent in
the following situations:-
* When the patient stops talking briefly to recollect his or her
thoughts.
* When the patient is overwhelmed by emotion and starts to cry.
Doctor should remain silent until the patient has regained
control of the emotional outburst.

9. Touching the patient for its therapeutic effect is a neglected

aspect of communication in modem medical practice, which
when used appropriately, is very useful to convey concern and
empathy to the patient. For example, feeling the pulse of a
patient who is distressed on hearing bad news or patting the
shoulder of an elderly patient at the end of the consultation,
could make the patient feel better and assured of the doctor’s
continuing support. However, the need to use touch is not
common. It should be used only if the doctor thinks it is
appropriate to do so in a particular situation and with due
regard for codes of professional conduct.
10. Communication during clinical examination - Although consent
for examination is implied when a patient consults a doctor, the
doctor should obtain consent before examination which is
mandatory in situations involving breast, vaginal and rectal
examinations. The patient will be anxious about the nature of
the clinical examination and about what the doctor may find.
The doctor should explain to the patient about the examination
that is required, what he or she is going to do, warn the patient
whether it will hurt, examine gently and watch the patient’s
face for signs of pain. The doctor should not instill anxiety in
the patient by expressing surprise at the findings on
examination. The patient’s privacy should be maintained at all
times and a sheet placed over areas that are not being
examined.
11. Reassurance should be given at the end of the medical
interview and examination. Reassurance should be realistic and
relevant to the patient’s condition.

12. Follow up and continuing support. - The patient should be told

what further symptoms to look for which may necessitate
another visit to the doctor. At the termination of the medical
interview, the patient should be assured of continuing support
and suitable follow up arrangements made.

Good communication means that the doctor should:

a. Find out what the patient thinks, fears and understands about
the illness - the doctor should be able to understand the
patient’s problems, as the patient sees it. This is important
because sometimes what the patient complains of is not what
he or she is really worried about eg. a patient may complain of
pain in the arm but what is really causing anxiety is about
getting a stroke because a relative had suffered from one
recently.
b. Make sure before the consultation ends, that the patient has
come to a shared understanding of the problem and the
proposed management with the doctor.

Ethical aspects of the doctor-patient relationship - The

 main principles are confidentiality, respecting patient’s
autonomy, obtaining informed consent, acting in the patient’s
best interests and doing no harm. These will be dealt with in
more detail in chapter 18.

Chapter 4

THE PROCESS OF CARE IN GENERAL

PRACTICE AND HOSPITAL SETTINGS
The process of care that takes place in primary care / general or
family practice settings is different to the process of care in hospital
settings. This is due to differences in the type and severity of the
illness, facilities available, the environment in which management is
instituted and the nature of the doctor- patient relationship. The types
of problems seen in primary care are common illnesses that are often
self limiting, chronic diseases that need long term care, serious
diseases in the early stages which may occasionally present as
emergencies and psychosocial problems. At the levels of secondary
and tertiary care, the diseases are more serious and sometimes even
life threatening, requiring specialist expertise, high technology
investigations and modem therapeutic procedures. In hospital
settings, the doctor plays a paternalistic and authoritative role
whereas in general practice / primary care, the autonomy of the
patient is paramount in the doctor-patient relationship.

It is important for students to understand the difference between

hospital practice and general practice, to prevent them from making
value judgments that one is superior or more correct than the other.
They have to appreciate the fact that the two settings are different
They have to understand that in hospital, the disease is a serious one,
so that management in a doctor controlled environment is very
necessary to prevent the patient from developing complications or
dying of the disease. In hospital practice therefore, treatment of the
disease is very important and has to take priority above everything
else.

In general practice / primary care, the patient’s personal and

family factors, working environment and psychosocial problems are
as important as the illness itself, which is often a common illness that
may even be minor and self limiting. Because the patient is an
ambulatory patient whose autonomy should be respected,
management is instituted in a patient controlled environment after
negotiating with the patient as to what could be complied with. The
doctor thus attempts to preserve the patient’s social functioning,
while giving the best possible treatment to the patient. Although the
treatment may not be the perfect medical treatment for the illness, it
is the best compromise between the doctor’s advice and what the
patient wants to do, according to his or her family and social
circumstances. So what is best for a particular patient may not
always be the ideal treatment for the illness but what can be
complied with by the patient.

The transaction of care in hospital practice (secondary and tertiary

care)
When a patient comes for admission to a hospital ward, the patient
may have been referred by another doctor. The patient will be
accompanied by anxious relatives as the illness will usually be a
major illness. The patient will give up his or her normal social role
and adopt the patient role, lose his autonomy and become passive
and dependent. Once the patient is in the ward, he or she will be
horizontal on a hospital bed and undressed for examination. The
patient will completely surrender himself or herself to the hospital
staff to cure the disease which is usually a serious one.

The next step in the transaction of care is when the hospital doctor
takes the history from the patient. The patient will be completely
unknown to the hospital doctor who has to therefore take a
comprehensive history. The patient’s story will be organised or
professionalised, as primary care doctors consulted earlier may have
mentioned what is possibly wrong. For example, a patient suffering
from hepatitis may say “ doctor, my liver is enlarged” or “I am
suffering from hepatitis” instead of complaining of loss of appetite,
vomiting and passing dark urine.
The doctor will perform a complete and systematic physical
examination and order blood tests, X rays etc which the patient will
have no choice, but to undergo. This is very important, because
unless the patient undergoes these tests, it may not be possible to
diagnose the disease. Once the reports are available, a precise
diagnosis will be made. Management will be instituted in a doctor
controlled environment and the patient will have little choice but to
undergo the prescribed treatment. This is very necessary as the
patient is usually suffering from a serious disease which may lead to
complications or even death, if not treated appropriately.
Finally, once the disease is cured or controlled, the patient will be
discharged from hospital to the community with instructions to
attend the hospital clinic for follow up care or to the family doctor
for continuity of care.

The transaction of care in general practice / primary care

The process of care in general practice/ primary care has many

differences from the hospital model. The whole process of the
consultation will be over in 6-10 minutes but may be longer or
shorter depending on the patient’s problem. The consultation is
usually initiated by the patient and the decision to consult will be
made after the patient has practiced self care and lay approval of the
sick role has been obtained. The patient will usually be suffering
from a minor illness, early stages of a major illness, chronic illness
or a psychosocial problem.
The patient will be known to the doctor who will greet the patient
and establish rapport. The patient in general practice will be upright,
be autonomous and retain normal social functioning, unlike the
passive hospital patient. The patient will have certain beliefs and
concerns about the illness. The patient comes to the family doctor
with the expectation that the doctor will find out what is wrong and
solve the problem as soon as possible with the least disruption of
social functioning.
The doctor will find out the reason for encounter by listening rather
than by direct questioning. The doctor will listen to the original story
in the patient’s own words and regarding fears, anxieties and family
problems etc. The doctor may need to identify the real reason for the
encounter, which may not be what the patient originally complains
of. Non verbal cues are as important as verbal cues in the family
practice consultation. The clinical examination will be local and
relevant or none at all. Most of the time the patient will remain
dressed, such as when the problem is a skin ailment or a
psychosocial problem. The patient would need to remove the clothes
for examination only occasionally, such as when the patient
complains of abdominal pain or a breast lump.

Investigations will be none or minimal as the family doctor will

always pay attention to the cost, inconvenience and discomfort to the
patient. Once data gathering is complete, the problem will be defined
in physical, psychological and social terms or even in symptomatic
terms. Often the illness is at an early undifferentiated stage and a
diagnosis is not possible. In such instances the doctor uses time as a
diagnostic tool and observes the patient over a period of a few hours
or days until more symptoms and signs develop.

Management is instituted in a patient controlled environment The

doctor would negotiate with the patient as to what he or she could
comply with in his or her particular social circumstances. The doctor
will take into account the home situation, work environment,
financial constraints etc. and will plan with the patient, a course of
action which would result in the least disruption of the patient’s
social functioning. The management itself may involve prescription
of drugs in a cost effective manner with explanation, reassurance,
preventive care, minor surgery etc. The consultation in family
practice ends with the doctor making follow up arrangements to see
the patient again if there is a change in the condition or if the patient
does not get better. Once the patient has recovered, he or she would
consult the doctor again only for a new episode of illness or for
ongoing care of a chronic problem or for preventive care.
 Chapter 5

CLINICAL DECISION MAKING

IN FAMILY PRACTICE

The clinical decision making process in family practice is patient-

centred, where even in the absence of a precise diagnosis, the
patient’s problem is defined in physical, psychological and social
terms and a management decision is made to solve the patient’s
problem. In contrast, in hospital practice, clinical decision making is
disease centred, where diseases are diagnosed in precise
pathophysiological terms and management is aimed at a cure.
The patient-centred approach has two broad aims:
1. To understand the patient and the illness (Patient’s agenda)
2. To diagnose the disease whenever possible (Doctor’s agenda)
1. Understanding the patient and the illness means understanding
the patient’s experience of the illness which may be a physical or a
psychological disturbance. It includes the patient’s concerns and
fears, discomforts and disabilities, sensations and feelings, attitude
towards himself, attitude towards the doctor and the effects of the
illness on the patient’s life. The patient may have his or her own
agenda and may be looking for answers to questions such as
‘what does this symptom mean?’
‘why has it happened to me?’
‘why now?’
‘ what will happen in the future?’

PATIENT WITH PROBLEM

 negotiate with patient

MANAGEMENT DECISION
Fig. 1 Patient Centred Clinical
Method

2. Diagnosis of the disease is the doctor’s agenda.The patient

centred clinical method is based on an understanding of the
biopsychosocial model of disease described by Engel in 1980. The
biopsychosocial. model shows the close relationship between the
mind, body and environment. It takes into account not only
biomedical aspects but also the psychosocial stressors contributing to
the illness and the effects of the illness on the patient’s life.
In the patient centred clinical method (Fig. 1), the doctor
communicates with the patient to find out why the patient has come.
The reason why the patient has come may not be merely the
symptom itself, but the fact that the patient and family have come to
a stage when they can no longer cope with the symptom due to the
discomfort and anxiety it has caused. On the other hand, it could be
due to the fact that there has been no response to self care.
The doctor tries to find out the reason for encounter (RFE). The first
problem presented by the patient may not be the real reason for
coming which may remain as a “hidden agenda”. For example, the
middle aged housewife who presents with aches and pains may have
a “hidden agenda” of wanting to talk to the doctor about feeling
depressed since her children got married and left home. The doctor
would define this patient’s problem as the “empty nest syndrome”.
Sometimes asking the patient “ what made you decide to come and
see me today?” may help to identify the real reason for coming.
Example: A 25 old woman with a swelling (ganglion) on the dorsum
of her wrist which had been present for sometime, may consult for
fear of a serious disease due to the fact that she had recently read in a
newspaper article that a lump anywhere on the body could be a
cancer.
Asking the patient whether there is anything else, may help to avoid
the patient from presenting another complaint, just when the doctor
thinks the consultation has come to an end. Termed the “exit
problem” or the “by the way syndrome” this may turn out to be the
real reason for coming.
The doctor will next try to elicit the psychosocial stressors associated
with the RFE and the patient’s fears and concerns, expectations and
effects of the illness on the patient’s activities, relationships and life
in general. This will comprise the psychosocial data.

The doctor will also focus on collecting information such as the

symptoms and history of the problem, physical signs on examination
and the results of investigations. If it is possible to arrive at a medical
diagnosis, the doctor will make a diagnosis but if not, the doctor will
assess the problem in symptomatic terms. Eg. back strain or fever.
This will constitute the biomedical data.

The final definition of the problem will be made on a combination of

the biomedical data and the psychosocial data. Management will be
instituted with or without a diagnosis after negotiating with the
patient. The important point to remember is that a management
decision could be made in family practice, with or without a
diagnosis. For example, the family physician could receive a night
call from a mother about her child having high fever. The doctor has
to make a decision whether to see the child immediately or whether
to give advice to the mother on how to manage the fever and to bring
the child the next morning for examination. So in this instance, the
doctor makes a management decision on the symptom of fever
without knowing the diagnosis or the cause of the fever.

This does not mean that family doctors do not make diagnoses.
When sufficient information is available to make a diagnosis, a
diagnosis will be made.

Diagnostic process or style of clinical reasoning

In the process of making a diagnosis or the process of problem
solving, doctors make use of four different clinical reasoning styles.
These are 1) algorithmic
2) exhaustive
3) heuristic
4) hypothetico-deductive
These are not mutually exclusive and a doctor may use one or more
of these styles during a single patient encounter.
The algorithmic style is based on a flow chart, where decision
making proceeds systematically along a series of branching decision
paths. Used for illnesses such as sore throat or dysuria, it is ideal for
inexperienced doctors or primary health care workers. The
exhaustive method is the one used in hospital practice where a
comprehensive history, complete and systematic physical
examination and extensive investigations precede the making of a
diagnosis of a serious disease. This method attempts to make sure
that the doctor does not miss any of all the possible diagnoses. Takes
up a lot of time and is useful for inexperienced people such as house
officers and medical students.

Hypothetico-deductive style of clinical reasoning

Fig.2 A model of the Diagnostic Process (Elstein et al 1978)

(Adapted from McWhinney Ian R. A Textbook of Family Medicine.
Oxford University Press 1989.)
The heuristic style is that of pattern recognition. The doctor
recognises disease patterns he has seen and learnt from past
experience. Useful for spot diagnosis such as eczema and otitis
media but this style may miss other important associated problems.

The style most commonly used by clinicians including experienced

hospital specialists and family physicians is the hypothetico-
deductive style of clinical reasoning. (Fig. 2) This is low cost and
efficient. It has been shown that experienced clinicians make their
first hypothesis within 30 seconds of the patient presenting the
problem and the final hypothesis within 6 minutes. During the
clinical encounter, the doctor selects certain items of information
which are called cues. These cues may be symptoms, physical signs,
aspect of patient’s behaviour, doctor’s previous knowledge of the
patient, doctor’s feelings about the patient, urgency of the
consultation etc. Based on the cues selected, the doctor generates one
or more hypotheses as to what is wrong with the patient.

The doctor then embarks on a search to look for evidence to support

the hypotheses. During the search unexpected cues or additional cues
may come up and the original hypothesis may have to be revised and
new ones formed. Therefore the doctor will go on generating, testing
and revising the hypotheses. The end point of the search is reached
when the doctor is left with one or more hypotheses on which a
management decision could be made. These hypotheses are then
arranged in rank order.

The rank order of the hypotheses is based on probability and pay off.

Pay off means the consequences of diagnosing or not diagnosing a

disease. The more serious a disease and the more amenable it is to
treatment, the greater is the positive pay off of diagnosing that
disease. This is because a patient with such a disease will get cured,
if the correct diagnosis is made and proper treatment is given. A
disease could have a negative pay off, if the doctor misses the
diagnosis, because missing the diagnosis could lead to death of the
patient. Therefore, those hypotheses with a negative or a positive pay
off should be high up in the rank order of the hypotheses, even if the
probability of the disease is low in that particular practice
population.

For example in a child with abdominal pain, the probability of acute

appendicitis is low, but it should be ranked high in the order of
hypotheses because of its positive pay off if detected early. Similarly,
the probability of meningitis in a child with fever and vomiting in
family practice is low but has a high negative pay off as the child
may die if the diagnosis of meningitis is missed.

Probability means the likelihood of a disease being present in a

patient of a particular age and sex with a given symptom in a
particular practice population. To know the probability of a disease
in a particular patient, the doctor must have previous knowledge of
the patient and a knowledge of the prevalence of disease in the
practice population.

For example if a young adult comes with a headache to the GP, the rank
order of the hypotheses will be sinusitis, tension headache and migraine. On
the other hand when a young adult is admitted to a neurology ward with a
headache, the rank order of the hypotheses may be subarachnoid
haemorrhage or brain tumour.

The final hypothesis on which a management decision is made will

usually be based on the symptoms and physical signs found on
clinical examination. Most of the time, GPs make use of their
clinical acumen when making a diagnosis and depend less on
investigations. It has been shown that most diagnoses are made on
the history alone. A study by Hampton et al 1973 showed that in
medical out patients, the final diagnosis agreed with the original
hypothesis on the history alone in 83% and that it was only in 8%
that the diagnosis changed after the results of investigations were
known and only in 9% did it change on the findings at physical
examination.

However, sometimes the doctor may need to order a few tests to

confirm the diagnosis or exclude a serious illness. The doctor will
always exclude the serious illness first, ie the hypothesis with a
negative pay off if the diagnosis is missed.

For example, in a middle aged male with chest pain, even if the pain is
atypical, the doctor will do an ECG to exclude a myocardial infarction which
has a greater negative pay off if the diagnosis is missed.
When requesting for investigations the doctor should be selective
and consider the usefulness or validity of the test versus the cost,
inconvenience, discomfort and risk to the patient who undergoes the
test. The doctor should also be aware that the validity of a test
depends on its sensitivity, specificity and predictive value which are
discussed in detail later on in this chapter.

In the hypothetic deductive system of clinical reasoning, the end

point of the search is reached when the doctor is left with one or
more hypotheses on which a clinical decision could be made without
risk to the patient. The GP is at an advantage due to the continuing
relationship with the patient. When there is no urgency to solve the
problem right away, the search can be stopped temporarily and
started again later. On follow up, the doctor may make a definitive
diagnosis or the patient may recover without a diagnosis ever having
been made.
At the end of the search for a diagnosis, the clinical decision on
management may be one or more of the following
1. There is no definitive diagnosis and the doctor decides to wait
and see.
2. The doctor decides to refer.
3. There is a definitive diagnosis and the doctor decides to institute
management

1. There is no definitive diagnosis and the doctor decides to wait

and see. The wait and see decision or ‘watchful waiting’ when
an immediate diagnosis is not possible, is also referred to as the
use of time as a diagnostic tool. This is very useful for family
physicians who often see illnesses in the early undifferentiated
stage when symptoms are vague and signs are minimal. Self
limiting illnesses are common which would make investigations
redundant and also incur unnecessary cost, inconvenience and
discomfort to the patient. On the other hand, the doctor who
uses time indiscriminately may sometimes miss the diagnosis,
thereby putting the patient at risk. Therefore watchful waiting in
managing clinical uncertainty should be done with care. The
doctor should educate and reassure the patient that the doctor
will keep a close watch and review the condition from time to
time. The family physician could also share his or her
uncertainty with colleagues when faced with a really difficult
problem. Managing clinical uncertainty is one of the keys to the
craft and science of general practice.
2. The doctor decides to refer. The decision to refer is made when
the doctor is not sure of the diagnosis or the patient is very ill or
appears to be suffering from a serious disease which needs high
technology investigations and appropriate treatment by a
specialist or in a hospital. Referral may take place with or
without a definitive diagnosis eg. an acute abdomen. When
referring, the doctor should explain to the patient on the need
for referral and what treatment to expect in hospital eg. a
surgical operation. Where emergencies are concerned, the
doctor should institute emergency treatment prior to referral and
inform the hospital about the treatment that has been given.
3. There is a definitive diagnosis and the doctor decides to manage
the patient. Clinical decisions on management will be based on
the medical diagnosis and the patient’s experience of the illness.
The doctor will discuss management options with the patient
taking into account other co-existing medical problems, the
family and life circumstances of the patient, socio economic
status, the wish or the ability to comply with treatment offered,
ethical issues etc. Therefore management is individualized to
suit each patient, after negotiating with the patient who has been
fully informed of the treatment options available and their costs
and benefits. Management decisions may also be influenced by
a number of extraneous factors such as the doctor’s uncertainty,
fear of medical litigation, patient factors and institutional
factors.

The validity of diagnostic tests and their interpretation

during the diagnostic process

Clinical problem solving in family practice is usually based on the

symptoms and physical signs found on clinical examination.
Sometimes the doctor needs to order tests to confirm the diagnosis or
to exclude a serious disease. When using diagnostic tests the doctor
needs to be aware of the usefulness or validity of a test. The validity
of a test depends on its sensitivity, specificity and predictive values.
Sensitivity, specificity and predictive values are properties of a test
that have been determined beforehand by comparing the test against
a gold standard for diagnosis of a particular condition. For example,
the ability of the urine full report to diagnose a urine infection as
against a urine culture which is regarded as the gold standard. These
properties of tests have to be found out by reading articles and
textbooks that have the best available evidence.
Table 1 shows how the sensitivity, specificity, predictive values both
positive and negative and the prevalence of the disease can be
calculated.
Sensitivity is the ability of a test to give a positive result in patients
with the disease.

No. of true positives

Sensitivity = ------------------------------- x 100
Total number of
people with the
disease
Specificity is the ability of a test to give a negative result in people
without the disease.

No. of true negatives

Specificity = ------------------------------- x 100
Total number of
people without the
disease
With a test that is 100% sensitive, all those who have the disease will
test positive and there will be no false negatives. This means that
those who test negative are true negatives and could be said to be
free of the disease. Therefore a highly Sensitive test which gives a
Negative result is useful in ruling out a diagnosis (mnemonic
SnNout).

With a test that is 100% specific, all those who do not have the
disease will test negative and there will be no false positives.
Therefore those who test positive are true positives who would be
having the disease. Therefore highly Specific test which gives a
Positive result is useful to rule in a diagnosis (mnemonic SpPin).

A test that is 100% sensitive is unlikely to be 100% specific and vice

versa. The disadvantage of a highly sensitive test is that it is likely to
yield a number of false positives and the disadvantages of a highly
specific test is that it is likely to yield a number of false negatives.
Therefore any test will have false positives or false negatives. Both
carry penalties for the patient. False positives means wrongly giving
a diagnostic label, to someone who does not have the disease. Such a
person would suffer from unnecessary anxiety and have to undergo
more tests, which may be invasive. On the other hand false
negatives, carry the risk of missing the diagnosis in a person who has
the disease and result in a delay in treatment. Therefore doctors need
to be aware of false positives and false negatives resulting from
diagnostic tests.

Sensitivity and specificity do not usually vary with the setting in

which the tests are done but vary with the stage of the disease.
For Example, in a child with suspected dengue fever, a test for IgM
antibodies which is a highly sensitive test between the 7th to the 10th day of
the illness may give a negative result if done earlier. Therefore, a doctor who
does the test too early in the illness and gets a false negative result, may
wrongly reassure the parents that there is nothing to worry. It is also
important that doctors do the PCV and platelet count from the 3 rd to the 6th
day to decide whether the child is developing dengue haemorrhagic fever or
not, rather than wasting money on the antibody test.

Sensitivity and specificity are of limited value in interpreting the test

results of an individual patient. The indices that are more useful are
the predictive values of a test, both positive and negative.

The positive predictive value is the proportion of test results that are
true positives. Therefore Positive predictive value or PPV = TP/
TP+FP x 100 or as in Table 1, a/a+b x 100. The denominator is all
those with positive test results.

Similarly, the negative predictive value is the proportion of test

results that are true negatives. Therefore the negative predictive
value or NPV = TN / TN + FN x 100 or as in Table 1, d/d+c x 100.
The denominator is all those with negative test results.

The positive predictive value (a / a+b) or the proportion of people

having the disorder amongst all those who give a positive result is
the posttest probability of the disorder being present. Positive
predictive value is useful as it changes the prior probability that the
patient has the disease in question. Prior probability of the disease
(prevalence of the disease) in all the patients in table 1, is (a+c) /
(a+b+c+d). It is important to remember that the positive predictive
value of a test takes into account the prevalence of the disease in a
population. If the prevalence is high, the positive predictive value is
also high and there are less false positives. If the prevalence is low,
the positive predictive value will be low and there will be more false
positives.

For example, in a tertiary care hospital, where cancer prevalence is

high, the positive predictive value for detecting cancer by endoscopy
in a patient with upper GI symptoms will be high. On the other hand,
the positive predictive value for detecting cancer by endoscopy in a
patient with upper GI symptoms in family practice would be low as
prevalence is low in this setting. Therefore a test which is useful in
specialist practice where the prevalence is high may not be useful in
family practice where the prevalence is low. The cost benefit is low
because a large number of people would have undergone the test
unnecessarily as most patients with dyspepsia in family practice
without accompanying danger symptoms (red flags) are not having
cancer and would have improved with medical treatment.

The other disadvantage would be the false positive results that could
arise due to the low prevalence, leading to more invasive diagnostic
and surgical procedures being done unnecessarily.

Table 1

Disease
 Sensitivity = a / (a + c) x 100
Specificity = d / ( d + b ) x 100
Positive predictive value or post test probability of having the target
disorder among patients with positive results = a / (a+ b) x 100
Negative predictive value or post test probability of not having the

Test results
Present Absent Total

True positives (TP) False positives (FP)

Positive a+b
a b

False negatives (FN) True negatives (TN)

Negative c+d
c d

Total a+c b+d

target disorder among patients with negative test results = d / (c + d)

x 100
Prevalence or pretest probability of having the disorder = (a+c) /
(a+b+c+d)
………………………………………………………………………
Adaptedfrom David L Sackett. A primer on the precision and
accuracy of the clinical examination. JAMA 1992;267: 19: 2638-
2644
Likelihood ratios are another way of interpreting information from
diagnostic tests. Likelihood ratios do not vary with the prevalence
and can be used for multiple levels of test results. Likelihood ratio
defines how much a positive or negative test result modifies the
probability of disease.

For tests that are simply positive or negative, the likelihood ratios
can be calculated from sensitivity and specificity by using the
formulae shown below.
Likelihood ratio (of having the target disorder) for a positive test
result (LR+) = sensitivity / (1 - specificity).

Likelihood ratio (of not having the target disorder) for a negative test
result (LR - ) = (1 - sensitivity) / specificity.

Post test probability of the target disorder (expressed as odds) = pre

test probability of the target disorder (expressed as odds) x likelihood
ratio for the test result.

The magnitude of the likelihood ratio can determine how strongly a

given test result will rule in or rule out a disease. The higher the LR
+, the more likely the disease is and the lower the LR - , the less
likely the disease is. In general an LR + of 10-20 would rule “in” a
disease and an LR- of less than 0.1, would rule “out” a disease. With
a likelihood ratio close to 1, the probability of disease will not
change.

If Likelihood ratios are known (LR+ or L R - ) and the clinician

determines the pre-test probability based on clinical experience,
prevalence statistics and clinical findings in the index patient, a
nomogram can be used to determine the post test probability of a
disease. (Figure 3)

It is important for clinicians who use diagnostic tests to confirm or

exclude a diagnosis to find out the sensitivity, specificity, predictive
values and likelihood ratios which assess the performance of a
particular test against a gold standard. Even if the values of these
indices are not readily available to practicing physicians, mere
awareness of the usefulness and limitations of diagnostic tests is
important to ensure sound decision making in clinical practice.

In addition to the use of these indices to assess the performance of

laboratory tests, they could also be used to interpret information
from the history and physical signs. For example, the number of
positive responses to the CAGE questionnaire to detect the problem
drinker or the degree of pallor in the diagnosis of anaemia.

In this day and age of evidence based medicine, all doctors should
make every effort to find out the best available evidence from
research papers and systematic reviews, with regard to the following
to ensure sound clinical decision making in family practice.

• Clinical epidemiology, disease prevalence and

disease causation

• Appropriate diagnostic tests together with their

sensitivity, specificity and predictive values and likelihood
ratios

• Treatment options available with their costs,

benefits, risks
Fig. 3. Nomogram for using likelihood ratios to determine
disease probability
(Adapted from David L Sackett. A primer on the precision and accuracy
of the clinical examination. JAMA 1992,267:19:2638-2644)

This nomogram helps you to interpret the results of a diagnostic test.

Identify your estimate of the pretest probability of the disease in your
patient on the left axis (likelihood of the disease based on clinical
findings and prevalence statistics). Draw a line or hold the straight
edge of a ruler from that point through the likelihood ratio for your
test in the middle axis until it meets the right axis. The point where
the line or the straight edge of the ruler crosses the right axis is the
post test probability; this is the likelihood of the disease based on the
diagnostic test.
 Chapter 6

PATIENT MANAGEMENT
IN FAMILY PRACTICE

Management of the patient in family practice is carried out in a

patient controlled environment because the family physician is
dealing with ambulatory patients in the community.
The family physician respects the autonomy of the patient and will
discuss and negotiate the management plan with the patient.
Negotiating with the patient should result in a management plan that
will
* be acceptable to the patient
* be the best solution to the patient’s problem
* lead to patient satisfaction
* achieve optimum compliance.
For example when requesting investigations, the doctor could
discuss with the patient where he could get the tests done, when he
should do it, how urgent it is etc. When discussing management, the
doctor will take into account the patient’s concerns and fears about
the illness, cultural and religious beliefs, expectations and
interpretations of the illness as well as the family and psychological
factors and the socioeconomic status.
The treatment of a patient’s illness or problem will be made to suit
each individual patient. Therefore the same illness may be treated
somewhat differently in different patients. Although it may not
necessarily be the ideal or the most perfect treatment for the illness,
it will be the best solution for a particular patient’s problem in his or
her circumstances.
Thus, management is individualised in family practice more than in
any other field of medicine. A study carried out by Howie (1976)
could be used to illustrate individualised management in family
practice. Howie circulated 16 standardised colour photographs of the
throats of patients who had complained of sore throat, to 1000
General Practitioners (GPs). A standard physical history
accompanied each photograph but the psychosocial history sent to
half the GPs (500) was slightly different to that given to the other
500 GPs. The GPs were asked whether or not they would prescribe
an antibiotic for each of the clinical situations given. The results
were analysed and the percentage of GPs prescribing an antibiotic in
each of the two groups, in paired contrasting psychosocial situations,
was compared. It was found, that the difference in the percentage of
doctors prescribing an antibiotic in the two groups for identical
photographs of sore throats but with different psychosocial histories,
was statistically significant. For example 23% of doctors in one
group prescribed an antibiotic where the history given, only
mentioned that the patient was an 18 year old university student. The
same photograph with a history of the patient being an 18 year old
university student, due to sit the degree examination the following
week, resulted in 69% of GPs in that group to state that they would
prescribe an antibiotic.

Management in family practice

Management of the ambulatory patient in family practice involves
one or more of the following
1. Investigations
2. Prescription
3. Explanation, advice and reassurance
4. Arrangements for follow-up
5. Counselling and supportive psychotherapy
6. Referral to consultants / community resources
7. Health promoton and preventive care
8. Procedures including minor surgery
9. Certification
 10. Emergency care

Investigations
The GP requests routine investigations on patients who come for
medical checkups and for patients with chronic diseases. With regard
to patients who come for illness care, most of the time the GP does
not request investigations because the illness is either a minor illness
eg. URTI or the diagnosis is obvious eg. eczema.
Sometimes, patients present in the early undifferentiated stages of a
serious illness where the symptoms are very similar to those of a
minor illness. In such instances the doctor uses time as a diagnostic
tool, for more information to become available to make a definitive
diagnosis or for the illness to resolve on its own. Sometimes the
doctor may combine time as a diagnostic tool, along with a few
preliminary investigations.
A family doctor requests investigations for any of the following
reasons:-
a) To confirm the diagnosis
b) To exclude a serious disease
c) To assess the severity of a disease
d) To determine the progress of a disease following treatment
The family doctor is selective in the use of investigations because of
the cost, inconvenience, risk or discomfort to the patient by an
investigation. The family doctor should also consider the validity of
a test depending on its performance based on sensitivity, specificity,
predictive values and likelihood ratios as described in the previous
chapter.
When a decision is made to request an investigation, it would be
useful therefore, for the doctor to ask himself or herself the following
questions :
Is this investigation necessary?
Will it change the management?
Investigations should be performed only when the following criteria
are satisfied.
* The information obtained from the results of the investigation
 cannot be obtained by a cheaper, less intrusive method eg.
taking a better history or clinical examination
* The value of the information gained outweighs the risks of the
investigation
* The results will directly assist in the diagnosis and have an
effect on subsequent management

Prescription
Rational prescribing is extremely important. When the time comes to
write a prescription, the doctor has to first decide whether to
prescribe and what to prescribe.

Whether to prescribe?
Whether a family doctor prescribes a drug or not is influenced by the
physician's habit, his or her postgraduate training and experience,
influence of the drug industry, patient expectations and so on.
Doctors usually prescribe drugs for therapeutic purposes which may
result in one or more of the following beneficial effects for the
patient.
* Cure of a disease
* Relief of symptoms
* Control of the disease process
* Prevention of complications
When prescribing for therapeutic purposes, the doctor would also
consider whether the natural history of the problem will be helped by
medication or not.

Sometimes doctors prescribe for tactical reasons such as

* to gain time for more information to become available
* as trial treatment
* to maintain professional image
* to terminate the consultation
* for the placebo effect
Prescription for tactical reasons should be kept to an absolute
minimum, making sure that the drug used is not likely to cause any
harm or undesirable effects on the patient.

What to prescribe?
What to prescribe will depend on a number of factors regarding the
particular drug and the particular patient to whom the drug is being
given to.

Drug factors
* Effectiveness and cost
* Contraindications to its use eg. beta blockers if the patient
has asthma
* Drug interactions to be avoided eg. antibiotics and oral
contraceptives
* Factors which influence optimal dosage and duration eg.
age, renal disease
* Possible side effects of the drug eg. dystonic reactions with
phenothiazines

Patient factors

* Age and sex of the patient and need for supervision

* Physiological status eg. pregnancy or breast feeding
* Whether patient has any other disease
* Whether patient is allergic or has had an adverse reaction to
the Drug
 Whether patient is taking any other medication
 The patient’s socioeconomic status
 Patient’s occupation, religious and cultural beliefs which
may influence compliance

Writing the prescription

Care should be exercised when writing the prescription. The general
guideline given below could be followed when writing a
prescription.

Features and components of a good prescription :

* Should be legible
* Patient’s name
* Age (very important for children below 12 years of age)
* Date
* Rx which means recipe
* Name of the drug, generic name should be written, brand
name optional
* Dose of the drug

* Frequency of the dose

* Timing of the dose eg. to be taken immediately, before or

after meals, in the morning or at night
* Route of administration if not orally eg. whether rectally or
for local application, for external use only

* Total quantity to be issued

* Signature of the doctor, name, designation, the Medical

Council Registration Number and the telephone number
If the prescription should not be repeated, it is important to write
below the prescription “do not repeat” (necessary for drugs which
should not be repeated without a doctor’s advice eg. anxiolytics,
antidepressants). If the doctor wants the patient (eg. a well controlled
hypertensive patient) to repeat another course of the drug before
coming back for follow up, the doctor could write repeat after 4
weeks or any other appropriate period of time and then place his or
her signature.

After writing the prescription, the doctor should tell the patient the
name of the drug, explain why it is being given, how and when it
 should be taken and warn about possible side effects.

Compliance with therapy

The best therapeutic plan is useless if the patient is unable or
unwilling to follow it. It has been shown that 50-92% of patients do
not follow prescribed medical treatment.
Optimum compliance could be achieved, if the doctor pays attention
to the following
1) A strong doctor-patient relationship
2) Effective two way communication
3) A simple affordable regimen
4) Clear and concise instructions

1) A strong doctor-patient relationship is the foundation for effective

patient education and compliance with medical advice. It has been
found that patients who are satisfied with this relationship are three
times more likely to follow a medical regimen correctly.

2) Effective two-way communication involves attentive listening,

genuine interest, empathy and concern for the patient. The doctor
should find out the real reason for the patient’s attendance as there
may be a “hidden agenda”. An accurate assessment of the patient’s
needs, beliefs and expectations by effective communication,
followed by negotiation may be necessary to decide on medication
which is acceptable to the patient. This will result in optimum
compliance with therapy.

3) A simple affordable regimen. The treatment schedule should be

simple and easy to follow and should be affordable. The patient
is more likely to take one drug than 2-3 different drugs. A drug
which is prescribed once a day or twice a day is more likely to
be complied with, than one that is prescribed three or four times
a day or 6 or 8 hourly. A simple regimen written in English,
such as one teaspoonful and not 5 ml will be understood better.
The doctor should also take into account the cost effectiveness
of a drug and the patient’s socioeconomic status so that an
 effective and safe drug that the patient can afford could be
prescribed.

4) Clear and concise instructions should be given. The doctor

should talk in the same language as the patient and not use
medical jargon that the patient may not understand. The
patient’s level of education should be taken into account and
giving inadequate or too much information should be avoided.
Sufficient information about the nature of the illness, why the
drug is being given, the importance of taking the drug as
instructed, common adverse effects which may occur etc. will
help to achieve optimum compliance with therapy. If the doctor
feels that the patient has not understood what he or she has said
about how to take the medication, it may be useful to ask the
patient to repeat it back to the doctor, to make sure it has been
understood correctly. Another method to be adopted is to write
on the reverse of the prescription in the language of the patient,
the number of tablets and the different times that they should be
taken.

Explanation, advice and reassurance

Giving a patient an explanation about the illness and advice and
reassurance are very important aspects of patient care in family
practice. In order to do this, a good doctor-patient relationship within
an atmosphere of mutual trust and confidentiality should prevail. The
therapeutic effect of the doctor was described by Balint, who stated
that the doctor is the most powerful drug in general practice. Balint
was of the view that it is the manner in which doctors prescribe
themselves by giving explanation, advice and reassurance to patients,
that play a part in their recovery. Showing concern and interest,
suggesting simple therapies that could be done at home, and giving a
patient education leaflet are aspects that are much appreciated by
patients.

Arrangements for follow up

Clear instructions should be given to the patient for review of the
condition and a follow up appointment should be made. If further
review is not necessary, it should be stated so. If there had been
uncertainty with regard to the diagnosis, it may be useful to arrange a
follow up appointment to see whether further symptoms and signs
would develop to make a definitive diagnosis. (Use of time as a
diagnostic tool). On the other hand, the doctor may treat a fever as a
viral fever and ask the patient to come back for review only if he or
she does not get better. The patient who recovers in two to three days
will not keep the follow up appointment as the illness has been
cured. Time has been used as a management tool in this instance.
Careful use of time as a tool in diagnosis or management is also
referred to as watchful waiting. Most often a follow up visit is
necessary to assess the patient’s response to management and
adverse effects of any drugs prescribed. Asking the patient to come
back for review is also useful to reinforce the advice given and to
clarify preventive measures to be taken. While follow up allows
family members to get involved in the care of the patient’s illness
when necessary, it also strengthens the doctor-patient-family
relationship.
Investigations, prescription, explanation, advice, reassurance and
arrangements for follow up described above are essential
components of the management of common presentations in family
practice which are minor and self limiting illnesses; long term care
of chronic disease; psychosocial problems and early stages of serious
diseases.
Counselling and supportive psychotherapy, referral, health
promotion and preventive care are carried out only in some
consultations and need special description. These topics are therefore
dealt with separately in the next few chapters. The ethical aspects of
procedures including minor surgery and certification will be dealt
with in the last chapter on ethical and legal issues in family practice.

Emergency care
Occasionally, the family doctor is faced with an acutely ill patient
where emergency care is needed. In such instances, there is no time
for negotiation with the patient. A quick assessment is made,
emergency care given while reassuring the patient and relatives, and
the patient referred to hospital if necessary. Examples are febrile
convulsions in children, acute myocardial infarction, acute severe
asthma, ruptured ectopic, haemorrhage following trauma, acute
anaphylaxis etc. In most of these emergency situations, the doctor
will institute emergency care and transfer the patient to hospital as
soon as possible.

To deal with emergencies, all practicing doctors need to have the

skills of carrying out cardio-pumonary resuscitation - ABC (Airway,
Breathing, Circulation). All doctors should have an emergency tray
ready with injectable preparations such as adrenaline,
hydrocortisone, diazepam, atropine, theophylline etc. It would also
be preferable to have an oxygen cylinder, mask, ambu bag etc for
resuscitation of an acutely ill patient as well as a nebulizer for those
in respiratory distress.

Chapter 7

REFERRAL IN FAMILY PRACTICE

Family physicians are usually able to manage most problems that

present to them in the family practice setting. Occasionally, the need
arises to refer the patient to a different level of care, such as when
there is a doubt about the diagnosis or when emergency care is
needed for an acute illness. Sometimes the patient needs to be
referred to another health resource in the community.
The family physician should not hesitate to refer to a specialist when
in doubt and should always give the benefit of the doubt to the
patient. The patient and family will respect and have confidence in a
family physician who refers when necessary, for the good and
welfare of the patient. The doctor should identify the need to refer
early and not wait until it is too late. Sometimes the patient or family
may indicate that they want to be referred and it is important for the
doctor to recognise this and consider referral to satisfy the patient.

Indications for referral

1. When there is a doubt about the diagnosis or management

and a specialist’s opinion is required.
2. When the illness is a serious disease that requires
investigation and treatment in hospital.
3. When the illness is life threatening and emergency
treatment is required eg. myocardial infarction
4. Where the patient’s condition though stable at the time,
could suddenly deteriorate and a period of observation In
hospital is required. Eg. patient after a head injury where
there has been an initial loss of consciousness at the time of
the injury.
5. When referral is required for a service available in the
community such as a rehabilitation centre.
There could be many other instances when referral is required and
the above examples are just some of them.

Consultation or Referral
When a doctor requests a second opinion from a specialist about the
diagnosis or management of a particular problem in a patient, it is
termed a consultation with the specialist. The specialist and the
family physician may see the patient together and discuss the
patient’s problem and its management. Such a consultation could
take place in a hospital setting or office practice setting. Most of the
time however, the family physician sends the patient to a specialist
with a letter and the specialist sees the patient and sends the patient
back to the family physician with advice regarding diagnosis and
management. In this day of advanced technology in information and
communication (ICT), consultations make also take place through
Telemedicine. This is specially so with regard to interpretations of
reports of radiodiagnotic procedures where a consultant radiologist’s
opinion is sought to interpret the findings in concurrence with the
doctor who is treating the patient.
Referral is where the family physician transfers the responsibility for
the care of a particular problem to a specialist or another physician
for a limited period of time. Eg. referring a patient to a surgeon for
an appendicectomy.
Whether it is a consultation with the specialist or a referral, the
family physician will go through the process of referral described
below and communicate with the specialist by writing a referral
letter or by making a phone call prior to the actual meeting of the
patient with the specialist.

Process of Referral
Once the doctor has decided to refer, the doctor should:-
* Explain to the patient why referral is necessary'.
* Inform the patient the type of specialist who should be
consulted for that particular problem and allow the
patient to choose the appropriate specialist. If the patient
cannot name a specialist in the relevant field, choose the
specialist.
* When selecting an appropriate specialist, the
family doctor should choose someone with whom he or she
has a good relationship. At the same time the doctor should
respect the patient’s personal preferences. The family
physician should select a specialist who has the appropriate
knowledge and skills for the specific problem and is
someone whom the patient will be able to approach easily.
* Decide whether the patient wants to be referred to
a private clinic or a clinic in the outpatient department
(OPD) of a government hospital. In the case of a serious
illness decide with the patient whether admission should be
 to a private hospital or government hospital. These
decisions will be guided by the patient’s socioeconomic
status. It will also depend on the facilities and expertise
available in a particular hospital.
Once all these factors have been sorted out, the family physician will
write the referral letter.
The doctor will usually write the letter on a letterhead which has the
doctor’s name, address and contact details. The date, name of the
specialist, his or her qualifications, designation and consultant status
should be written first.
The letter should contain the following information about the
patient:-
* Patients name and age.
* Presenting symptoms.
* Physical signs elicited by the doctor.
* Results of investigations if available.

* What has been done so far and details of drug treatment

given.

* Relevant family and social history eg. the patient’s

occupation or living environment, family situation or whether
the patient is breast feeding an infant etc.

* Relevant past history and details of any co-existing medical

conditions.
* Any drugs that are being taken concurrently.
The letter should end with a statement of what the family physician
expects from the specialist.
* Whether it is advice regarding diagnosis and management? (a
consultation)
* Whether the family physician wants the specialist to take over
the patient for investigation and treatment in hospital? (a
referral)
* Whether the patient is being referred for surgical treatment?
(a referral)
Communication between the referring physician and the consultant
must be done well. It is important for the referring doctor to transfer
all the necessary information including laboratory reports of the
patient, so that unnecessary duplication of tests is avoided. It is also
necessary to inform the specialist about treatment that has already
been given.

When the doctor refers the patient for emergency care of an acute
illness, it is very important to indicate what treatment has been given
immediately prior to referral. Eg. whether any sedative has been
given such as morphine, so that the hospital doctor will know why
the patient is drowsy. It is also important to write the details of any
other drugs that the patient is taking or has been given. For example
if a patient who has been on long term theophylline is referred for
treatment of acute severe asthma, it is important to inform the
hospital doctors about it, so that they will avoid intravenous
theophylline which could precipitate an arrythmia.

Once the referral letter is written the patient should be told what to
expect in hospital, whether he or she will have to undergo surgery
and so on. In this way the family doctor could prepare the patient and
make the patient less anxious when he or she is admitted to hospital.
The family doctor may call an ambulance for the patient, phone the
hospital and inform them that a bad patient is on the way. Family
doctors who provide personalised care to patients will sometimes go
to the extent of taking the patient in their own car in case of an
emergency.

Once the family physician refers a patient, the doctor’s responsibility

does not end there. The family physician may phone the consultant
and discuss the patient’s problem or communicate with the hospital
doctor regarding the patient. Sometimes the family doctor will visit
the patient in the hospital.

It is important to remember that referral is a two way process. A

family physician who has referred a patient for a consultation or a
referral, will expect the specialist to refer the patient back. If the
specialist sends the patient back with a reply, the patient usually
brings the letter to the family doctor who will take the trouble to
discuss the problem and help the patient to understand the illness and
its implications. Sometimes the specialist may not send a reply and
occasionally the patient may not come back to the family doctor at
all but remain with the specialist. Fortunately patients who value
having their own family doctor will always come back, even if it is
for another problem at a later date.

There should be a good relationship between the family doctor and

the specialist. Good communication between the specialist and the
family doctor will result in better patient satisfaction and the best
possible medical care for the patient. In countries such as the UK and
Australia, communication between the family doctor and the
specialist is well established, as the GP is the gate keeper to
specialist care in those countries.

To ensure that the patient complies with the referral, the doctor
should make the patient understand that the doctor will continue to
remain responsible for the patient’s welfare, so that the patient will
not feel that he or she is being rejected by the referral. Therefore,
adequate explanation of the need for referral and reassurance that the
doctor will continue to be in charge of the patient and will coordinate
the care, should be emphasized. If the patient has co-existing
multiple problems, the family physician should take the
responsibility of coordinating the care given by one or more
specialists at the same time.

After the patient has got over a particular problem for which referral
had been done, the patient usually comes back and continues with
the family doctor for all future consultations.
When a patient needs to be referred to any other health resource in
the community, the same process of referral with slight modifications
should be followed.
Other health resources in the community to which family physicians
could refer their patients are listed below.
* Child welfare, antenatal clinics and family planning services
conducted by the Medical Officer of Health
* Help Age or Homes for the Elderly
* Organizations that help abused women eg. Women in Need
 * Community Mental Health Centres eg. Sahanaya
* Professional Counsellors eg. marriage counsellors, student
counsellors
* Rehabilitation of alcoholics and drug addicts eg. Alcoholics
Anonymous
* Services and homes for physically handicapped children
* Educational services for mentally retarded children
* Physiotherapy services, Home nursing services
* Self help and support groups

Chapter 8

HEALTH PROMOTION AND

DISEASE PREVENTION

Health promotion and disease prevention are integral components of

family practice.

Health promotion
“Health promotion is the process of enabling people to increase
control over, and to improve, their health. It moves beyond a focus
on individual behavior towards a wide range of social and
environmental interventions.”
World Health Organization

“Disease prevention focuses on prevention strategies to reduce the

risk of developing chronic diseases and other morbidities. “

A state of complete health refers not only to the absence of disease

but the presence of physical, mental and social well being. While it is
not possible for a person to be in such a state of complete health all
the time, it is important for doctors to promote patients to lead
longer, happy and meaningful lives. Therefore, health promotion
should be practised by family doctors so that the health and quality
of life of their patients would improve.

Health promotion could be done through posters with health

education messages in the doctor’s waiting room. Such posters could
include a wide variety of information eg. immunization, nutrition,
breast feeding, substance abuse, road safety, cancer screening,
physical exercise, relaxation techniques to overcome stress etc.

Health promotion could also be done at an individual level by

identifying patients at risk and giving them appropriate advice.
Faulty behaviours could result in poor health and reduction in
longevity and such patients could be empowered to lead healthy life-
styles by behaviour modification. Although compliance may be a
problem, it is the doctors duty to help patients bring about a change
in faulty behaviours.
Thus, a family doctor’s day to day work affords many opportunities
for health promotion such as educating patients and counselling them
on how to lead healthy life-styles to attain a state of optimum health.
Individual counselling could also be reinforced by giving the patient
a health information leaflet. Referred to as opportunistic health
promotion, this may include any of the following:-
* Eating a healthy diet.
* Engaging in regular physical activity and exercise.
* Avoiding substance abuse.
* Coping with stresses of every day life and stress
management.
* Promotion of exclusive breast feeding of infants up to 4
months.
* Advising adolescents to resist peer pressure so that
indulgence in substance abuse and unsafe sexual activities
are minimised.
* Explaining the advantages and disadvantages of hormone
replacement therapy (HRT) to menopausal women.
While these are just a few examples, family doctors should
 encourage their patients to engage in any health promotion activity
that is relevant to a particular patient. This is not so difficult for
family doctors because of the long term doctor- patient
relationship.

Disease prevention
The family physician could practise preventive care at all three
levels, primary, secondary and tertiary.
Primary prevention is action taken to prevent a disease from
occurring at all in an individual at risk. The best example would be
immunization where children are immunized against the major
childhood infectious diseases.

Another example of primary prevention is health education. For

instance, educating the mother of an infant with a diarrhoeal illness
about hygienic preparation of the baby’s food, may prevent another
episode of diarrhoea. On the other hand, the doctor could educate a
patient with chronic bronchitis to stop smoking to prevent that
person from developing a myocardial infarction later on in life.
Therefore the opportunity arises at almost every consultation to give
health education. Other examples of primary prevention carried out
by the family physician are chemoprophylaxis, family planning etc.

Secondary prevention is early detection and treatment. Diseases

could be detected in the early pre-symptomatic stage and this is
referred to as screening or case finding. The doctor does this by
screening procedures to detect a disease which is established in the
host but has not yet caused any symptoms. Examples are where the
doctor checks the blood pressure in a middle aged patient who
consults for a respiratory infection. Another example is detecting
anemia in a pregnant mother or doing a cervical smear in a 40 year
old woman. A doctor who detects a disease by a screening test is
responsible for investigating and instituting appropriate treatment for
that patient.

Secondary prevention is also early detection and treatment of

diseases in the symptomatic stage and this is what most doctors are
doing when they give illness care to patients who consult for
symptoms. Family physicians are therefore most of the time
practising at the level of secondary prevention, by detecting and
treating diseases in the early stages to prevent the onset of
complications. Examples are dengue haemorrhagic fever,
pneumonia, diabetes mellitus, urinary tract infections etc.

Tertiary prevention is action taken when the disease is stabilized and

complications have already arisen, to prevent further disability and to
rehabilitate the individual to the highest possible level of
functioning. For example, the doctor could refer a patient who is
recovering from schizophrenia to a community mental health centre
for rehabilitation. The family physician is practising tertiary
prevention when arranging physiotherapy for a patient who has had a
stroke or when a drug addict is referred to a rehabilitation centre.
Giving drugs for pain relief to a patient dying from cancer known as
palliative care, is also a form of tertiary prevention.

When a particular patient consults a doctor for any problem, the

family physician should take the opportunity to practice preventive
care.
A systematic way of approaching preventive care on an individual
basis, is to use the mnemonic RISE. So at each and every
consultation the doctor should think of the following:-
R - Risk factor identification (are there any risk factors to be
identified eg. family history of ischaemic heart disease,
occupational risk factors etc.)
I - Immunization (is it necessary to immunize this patient eg.
rubella immunization for a 11-12 year old girl or tetanus
toxoid for a patient who has had an injury)
S - Screening (are any screening procedures indicated eg.
checking BP and lipid profile in a middle aged male or a
cervical smear in a sexually active female)
E - Education (what should this patient be educated about eg.
importance of hygienic preparation of food to a mother whose
child has developed an infective diarrhoea or the importance
 of weight reduction to an obese patient with osteoarthritis)
A guide on the preventive care activities that a family physician
could carry out in patients belonging to different age groups in
family practice are given below.

Newborn and infants

* Detection of congenital abnormalities eg. cleft palate, spina
bifida, congenital heart defects, congenital cataract, congenital
dislocation of hips, talipes
* Weight
* Head circumference
* Fontanelles
* Umbilicus
* Developmental milestones
* Vision, squint
* Language, vocalisation
* Genitalia for labial adhesions, undescended testis,
* Hernia
* Sleep problems, feeding problems

Toddlers and pre-school children

* Detection of Congenital dislocation of the hips (CDH)
* Detection of Congenital heart disease (CHD)
* Growth monitoring
* Developmental milestones
* Detection of hearing defects
* Detection of visual defects such as strabismus, refractive
errors
* Detection of urinary tract infections
* Prevention of home accidents
* Immunization against childhood diseases
* Education and prevention of dental caries
* Management of diarrhoeas and acute respiratory infections
(ARTs)
* Treatment of worms, scabies and lice
 School children
 Detection and management of behaviour problems
 Weight and height
 Vision
 Hearing
 Immunization
 Prevention of common illnesses
 Prevention of accidents
 Prevention and treatment of dental caries
 Detection and treatment of scabies and lice
 Treatment of worm infestations

Adolescents
Education about prevention and detection of
* Alcoholism
* Smoking
* Narcotic drug dependence
* Sexual problems and sexually transmitted diseases
* Advice on management of psychosocial problems
* Examination stress
* Family conflicts

Pregnant mothers
Education in preparation for labour
Education in preparation for breast feeding
Identification of high risk pregnancy
Detection and management of
* Anaemia
* Pregnancy induced hypertension
* Sexually transmitted diseases
* Rh incompatibility
* Asymptomatic bacteriuria
 * Malnutrition
* Gestational diabetes
Adult females
Detection and treatment of
* Hypertension
* Hyercholesterolaemia
* Carcinoma cervix
* Carcinoma breast
* Diabetes
* Menopause

Adult males
Detection, prevention and treatment of
* Alcoholism
* Smoking
* Marital and sexual problems
* Cancer of the prostate
* Cancer of the colon
* Hypertension
* Diabetes
* Hypercholesterolaemia

Elderly >65 years of age

Detection and treatment of
* Hypertension
* Diabetes mellitus
* Heart failure, atrial fibrillation
* Anaemia
* Depression
* Cancer
* Hypothyroidism
* Visual defects such as cataracts and glaucoma
* Hearing defects due to wax or nerve deafness
* Dental caries
* Osteoporosis
* Dementia
 Chapter 9

ILLNESS IN THE COMMUNITY

AND CONTENT / PROFILE
OF FAMILY PRACTICE

Illness In the community

Studies of illness in the community have shown, that only a small

fraction of health problems in the community come to the attention
of doctors. For example, the survey by White et al in 1961, found
that for 1000 persons over the age of 16 years in a given month, 750
had suffered symptoms but only 250 had consulted a doctor. (Fig. 1
Chapter 1) The same study repeated by Larry et al in 2001 showed
that for every 1000 men, women and children, 800 experienced
symptoms but only 327 considered seeking medical care. (Fig. 2
Chapter 1). In Sri Lanka no published surveys are available on
symptom occurrence in the population or the people’s health needs
as perceived by them.

Population surveys in the UK have shown that 90% of adults

reported having symptoms in a two week period, of which only one
fifth had consulted a physician. Thus, it appears that having
symptoms is the norm rather than the exception. Therefore, what is
important is not whether symptoms are present or not but how
serious, frequent and severe a symptom is and how a symptom is
acted upon by the person suffering from it. In other words, how do
people behave when they are ill?
Illness behaviour
Mechanic (1962) defined illness behaviour as ‘ the ways in which
given symptoms may be differentially perceived, evaluated and acted
(or not acted) upon by different kinds of persons’
The way in which a person reacts to symptoms is therefore an
individual matter and may be due to many reasons which are
independent of the severity of the illness. For example, consider a
person who has a mild diarrhoea with just three loose motions.
This symptom may be acted upon in the following ways
* One person may ignore the symptom
* Another may use home remedies or self care
* Another may decide to consult a doctor

Self care
Self care refers to all actions taken by the sufferer or the family to
overcome the symptoms the person is suffering from.
Self care may take many forms
* The sufferer may decide what to do about the
symptom
* Family, friends, relatives, neighbours etc. may give
advice as to what should be done to overcome the symptom
or illness.
* The sufferer may obtain over the counter (OTC)
medication, ie the person will go to a pharmacy and ask the
pharmacist for a medicine which could cure the illness. This
occurs commonly for upper respiratory tract infections
(URTIs), bowel complaints, pain, skin disorders etc.
If there is no response to self care, these sufferers of symptoms will
decide to enter the sick role and consult a doctor at the level of
primary care, who may be an MBBS qualified doctor or a
practitioner of an alternative system of medicine. Some persons will
not practice self care but enter the sick role straightaway and consult
a doctor. Variations in illness behaviour are so great, that it has been
found that some do not consult even when they have serious
symptoms, while others consult for very minor symptoms.
Sick role
Illness behaviour such as the decision to consult and enter the sick
role is determined by a number of factors such as age, sex, social
class, ethnicity, personality, previous illnesses, health beliefs,
difficulties in contacting a doctor, poor experience with doctors, past
experiences of medical care etc. It has been found that females
consult more than males, people from poor social classes consult less
though they have more symptoms and those who are under stress and
anxiety consult more and so on.

Once the decision to consult has been made, the sufferer of the
symptom enters what is called the sick role. A person in the sick role,
occupies a special place in society. The sick role entitles a person to
certain privileges. The person in the sick role also has to fulfill
certain obligations.

Privileges are that the person will be exempted from his or her
normal social duties and will not be held responsible for the resulting
incapacity. However, patients’ suffering from minor illnesses such as
a cold may not make use of the privilege and continue with his or her
duties.

The obligations are that if a person is to continue in the sick role, that
person is obliged to seek medical help and make every effort to get
better as soon as possible. Exception to this is an incurable illness
such as cancer or AIDS where the patient occupies the sick role for a
long period of time and has sought medical help but to get well is
beyond the patient’s own capability.

Illness and Disease

Family physicians / GPs who practice at the level of primary care or
first contact care, usually see patients in the early undifferentiated
stages of illness, when symptoms are often vague and positive
physical signs are minimal. It has been found that 15-40% of
problems seen at this level of care cannot be given a specific
diagnostic label. It is important for doctors entering general practice
to be aware of this, because they may dismiss symptoms as trivial
when a diagnosis cannot be made.
Thus a distinction should be made between illness and disease.
Disease is a defined biophysical abnormality.
Illness is a reduced capacity for the effective performance of tasks
which the patient expects to be able to do.
These definitions are useful for practicing doctors who find it
difficult to diagnose diseases in every patient seen by them. Patients
consulting the GP could be considered as belonging to three different
groups. The three circles in Fig. 1 show the three categories that
constitute the overlapping areas of the doctors work.

Fig.l The Overlapping areas of the doctors work.

(From Wright HJ and MacCadam DB, 1979)

B - Patients in the circle marked B will have symptoms and feel ill
but will not have a definable disease.
A - Patients in the circle marked A will suffer symptoms, feel ill and
have a definable disease
C - Patients in the circle marked C will have a definable disease but
will not complain of any symptoms or feel ill.

Let us take an example to describe patients in each of these three

groups.

B - A woman complains of pain in the knee when walking and

climbing steps, but the doctor cannot detect any swelling,
warmth, redness or restriction of movement of the knee. The
results of investigations are negative. This patient is ill,
because she experiences a reduced capacity to perform the
 tasks she expects to do, but the doctor cannot diagnose a
disease. Doctors are not happy when they see patients like this,
because they have to work within a concept of uncertainty and
manage the patient symptomatically with the hope that the
patient will improve. In some instances, the doctor may find an
underlying psychological or social factor contributing to the
illness or sometimes may not find anything, although the
patient continues to feel ill.
A - A woman complains of pain in the knee and difficulty in walking
and climbing steps. On examination, her knee joint is swollen,
there is crepitus on movement of the knee and the X ray shows
changes of osteoarthritis. This patient therefore has an illness
and a disease. With such a patient the doctor feels comfortable,
because doctors have been trained to diagnose diseases for
which specific treatment could be instituted. Once the
treatment is given, the doctor expects the patient to comply
with treatment and get better.
C- A woman who has her knee x rayed following a fall may be
found to have signs of osteoarthritis, although she had not
complained of pain or any symptoms prior to the fall. This
means that the disease had become chronic or stabilised and
was perhaps causing only minimal discomfort which the
patient was able to tolerate. Patients with disease but have no
symptoms also include patients in the early pre- symptomatic
stage of diseases such as hypertension or cervical cancer,
where detection is by screening tests.

Thus, the primary care doctor has the responsibility of not only
diagnosing and treating the patients who have symptoms and a
diagnosable disease, but also to manage those who are ill and not
diseased, and carry out screening procedures to detect patients in the
pre-symptomatic stage of a disease where early treatment is
important.

The Content and Profile of Family Practice

The content of family practice describes the pattern of health
problems dealt with by family physicians at the level of primary
care. The National Ambulatory Medical Care Survey conducted
annually in the USA, identifies the most common reasons for office
visits to physicians. National morbidity surveys are carried out at
regular intervals in countries such as the UK, Australia, Singapore
and Hong Kong while in the Netherlands and France such data are
collected through computerised information systems.

In Sri Lanka there is no system for routine collection of outpatient

morbidity data. Of the three surveys on primary care morbidity
conducted in the government sector, the first was a one day census of
outpatient morbidity as part of a Health manpower study in 1973 and
the other two were restricted by region or institution. While several
surveys have been carried out by solo family physicians in their own
practices, the first nationwide general practice morbidity survey in
Sri Lanka was the ‘One Day General Practice Morbidity Survey’
carried out by de Silva and Mendis 1996. In this survey, a random
sample of general practitioners collected data on consecutive patients
seen by them in the course of one single day.

The findings from this survey showed the morbidity pattern or

content of family practice in Sri Lanka and the results are shown in
Tables 1,2,3, & 4. The International Classification of Primary Care
(ICPC) which is compatible with ICD-10 was used to classify the
reason for encounter (RFE) or the demand for care by patients
consulting the GP and the problems that had been managed by the
GPs.
The ICPC is the ideal classification to classify health problems seen
in primary care, because the great variety of health problems brought
by patients could be classified into appropriate rubrics. It could be
classified according to the reason for coming as stated by the patient.
(Reason for Encounter or RFE). It could also be classified according
to the diagnosis or where there is no definite diagnosis as a symptom
or as the problem defined by the GP Even procedures such as check
up of BP, laboratory investigations and results of tests could be
classified according to the 17 chapters, seven components and
individual rubrics of the ICPC.

Table 1
Reason for Encounter (RFE) by ICPC Chapter

(Total RFE = 3448)

_______________________________________________________
ICPC CHAPTER PERCENT
_______________________________________________________
Respiratory 31.6
General and unspecified 23.4
Digestive 11.8
Musculoskeletal 8.0
Skin 7.1
Neurological 6.6
Female genital (including breast) 1.8
Circulatory 1.8
Pregnancy, childbearing and family planning 1.6
Endocrine, metabolic and nutritional 1.6
Ear 1.4
Urological 1.1
Treatment, procedures & medication 0.6
Diagnostic and preventive 0.6
Psychological 0.5
Male genital 0.3
Referral & other reasons for encounter 0.1

Table No. 2

Problem Definition (PD) by ICPC chapter

(Total PD =2087)

ICPC CHAPTER PERCENT

Respiratory 28.1
General and unspecified 16.5
Skin 14.5
Digestive 11.7
Musculoskeletal 6.2
Circulatory 4.5
Pregnancy, childbearing and family planning 3.9
Endocrine, metabolic & nutritional 2.2
Ear 2.1
Blood and blood forming organs & lymphatics 1.9
Psychological 1.9
Female genital (including breast) 1.8
Neurological 1.7
Urological 1.7
Male genital 0.6
Treatment, procedures & medication 0.3
Diagnostic and preventive 0.2
Referral & other reasons for encounter 0.1
Social 0.0

Table 3

Reason for Encounter (RFE) by ICPC rubrics

(Total RFE = 3448)

ICPC Rubric Name ICPC Code %

1) Fever A03 16.8

2) Cough R05 16.7
3) Sneezing/nasal congestion/runny nose R07 6.2
4) Headache NO1 4.8
5) Short of breath, dyspnea, breathlessnessRO2 3.3
6) Wheezing RO3 2.9
7) Diarrhoea D11 2.4
8) Pain-generalized / unspecified A01 1.9
9) Vomiting (Excl.. preg W06) D10 1.9
10) Abdominal pain - other localized D06 1.7
11) Wound S29.01* 1.7
12) Redness/erythema/rash localized S06 1.6
13) Back symptoms/complaints L02 1.5
14) Pruritus, skin itching exc. Ano SO2 1.4
15) Abdominal pain, cramps general D01 1.4
16) Chest pain general A29.01* 1.3
17) Sore throat R21.01* 1.2
18) Foot and toe symptoms/complaints L17 1.2
19) Blood Pressure check K39.01* 1.2
20) Leg/thigh symptoms/complaints L14 1.2
21) Worm treatment request D50.01* 1.0
22) Appetite loss (excl. T06) T03 0.9
23) Dizziness N17.02* 0.8
24) Earache /Pain H01 0.7
25) Knee symptoms/complaints L15 0.7
26) Hand & finger symptoms/comp L12 0.6
27) Accident/injury nos. A80 0.6
28) Nausea D09 0.6
29) Family Planning - Depo provera W14.01* 0.6
30) Menstruation delayed X07.01* 0.6
* Four digit codes refer to special ‘in house’ code numbers added by the
authors to the rubrics in the ICPC to identify common reasons for encounter
in Sri Lanka.
Table 4

Problem Definition (PD) by ICPC rubrics

(Total PD = 2087)

ICPC Rubric Name ICPC Code %

1) Viral fever A77.01* 11.1
2) URTI (head cold) R74 7.2
3) Bronchitis acute R78.01* 6.5
4) Asthma R96 4.7
5) Gastroenteritis D73.01* 2.4
6) Wheezy Bronchitis R99.01* 2.4
7) Sinusitis acute R75.01* 2.3
8) Hypertension uncomplicated K86 2.2
9) Gastritis D87.02* 2.1
10) Worms/Parasites D22 1.7
11) Pregnancy confirmed W78 1.6
12) Diabetes mellitus T90 1.6
13) Tonsillitis acute R76 1.3
14) Muscle pain/myalgia, fibrositis L18 1.3
15) Dermatophytosis S74 1.2
16) Urinary Tract infection-non Ven U71.02* 1.2
17) Ulcer Chronic S97.02* 1.2
18) Laceration S18.02* 1.1
19) Cellulitis localized S10.03* 1.1
20) Otitis media/myringits acute H71 1.1
21) Infected wound S11.01* 1.0
22) Worm treatment request D50.01* 1.0
23) Anaemia other/unspecified B82 1.0
24) Bronchiolitis acute R78.02* 1.0
25) Family Planning - Depo provera W14.01* 0.9
26) Eczema S87.02* 0.9
27) Wound S29.01 0.9
28) Malaria A73 0.8
29) Allergy/Allergic reactions NOS A12 0.7
30) Osteoarthritis of knee L90 0.6

*Four digit codes refer to special ‘in house’ code numbers added by
the researchers to rubrics in the ICPC to identify common problems
in Sri Lanka.
The One day general practice morbidity survey shows the common
reasons for which patients in Sri Lanka consult doctors and the
common problems that are managed by the GPs. To summarize the
findings by ICPC chapter, Respiratory and General chapters
accounted for 55% of the Reasons For Encounter (RFEs); by ICPC
rubrics, 27 of the top 30 RFEs were for common symptoms; with
regard to problems managed, asthma, hypertension and diabetes
were among the top twelve. The RFEs indirectly determine the
health needs of the population. The problems defined by the GPs
give an idea of the common health problems or pattern of morbidity
at the level of primary care in the community. The picture of the
pattern of morbidity in general practice in this survey is not very
different to that seen in GP settings in other countries.

The survey also showed the practice profile and the GP profile.
Significant features of this survey which illustrated the profile of
family practice are the following:-

Children under 12 years accounted for one third of all consultations.

The proportion of children under 12 and the proportion of the elderly

in the consulting population, were significantly higher than their
respective proportions in the general population.

More females (53%) than males (46%) were found in the consulting
population.

The majority (72.5%) of the visits were for initial episodes of illness.
This shows that most people consult for acute illnesses than for
routine visits, check ups and follow up care. This is because people
are willing to pay GPs who are available and accessible in the
community for the care of acute illnesses, while for routine visits and
follow up care they prefer to use the state run health services which
are free of charge.

GP profile among the random sample of GPs participating in the

study were the following:-

All the GPs who responded were from the four provinces where 64%
of the population live. In the random sample there were none from
the three provinces with low population density. This shows that
there is a dearth of GPs in rural areas. The male to female ratio was
7:1. More than 55% had postgraduate qualifications and 70% were
solo practices. The average number of patients seen per day was 74.
On the basis of the findings from this survey it was estimated that the
total number of general practice consultations in Sri Lanka amounts
to approximately 12.7 million consultations per year.

Surveys such as the above, need to be carried out at regular intervals

in all countries to monitor the health needs of populations which
should then be the basis for determining the distribution of health
manpower and the design of medical curricula. The content and
profile of family practice shown by this survey, would be useful in
designing the family medicine curriculum of medical schools in Sri
Lanka.

Chapter 10

THE FOCUS ON ‘FAMILY’

IN FAMILY PRACTICE

The family physician is concerned with the care of the whole person
in the context of the family and community on a continuing basis.
Family doctors who have undergone training in family practice
always tend to ‘think family’ when treating their patients. Such
doctors are aware that problems could arise in families due to
individual medical problems as well as from disturbances within
relationships between family members. A family doctor who has an
insight into the patient’s family, would be in a better position to
manage problems brought by individual members of the family.
Physicians who practice with a family focus see the doctor-patient
relationship not as a dyad but as a therapeutic triangle that involves
the patient’s family as well.

Knowledge of family dynamics is necessary to manage family

problems. Family dynamics refers to the ways in which family
members interact with each other and in relation to the family as a
whole. Families are complex units bonded by strong emotional
connections. Communication between family members, accepted
traditions or norms within the family and behavioural patterns are all
a part of family dynamics. New members who join the family
through marriage may bring along the history of their family of
origin that will influence the family dynamics.

To understand family dynamics, the family physician needs to be

aware of family structure and function, family roles, stages of the
family life cycle, impact of unexpected life events and impact of
chronic disease on the family and family systems assessment tools.

The family in health

What is a family ?

According to the dictionary, a family is defined as a group of

individuals consisting of parents and their children. This definition
refers to the biological family.
In present day society, groups of individuals who do not conform to
this definition may live together as a family. Therefore, if the family
is considered as a social unit, a family could be defined as a group of
individuals sharing emotional bonds, a history and a future.
The actual structure of a family varies between one family and
another while most of the basic functions remain the same.

Family structures

A nuclear family is one that is composed of a father, mother and

children or a husband and wife without children.

An extended family is where the nuclear family as well as those

beyond the nuclear family related by blood or marriage, such as
parents, aunts, grandparents, nieces and nephews live under one roof.
Common examples are elderly parents living with a married child
and grandchildren or a household where an aunt or uncle live with a
nuclear family. The nuclear family and the extended family are
referred to as traditional family structures and are the commonest
family structures found in Sri Lanka and South Asian countries.

In contrast, in western countries traditional family structures are rare.

For example, in the USA in 2000, nuclear families with the original
biological parents constituted roughly 24.1% of American
households, compared to 40.3% in 1970. In the UK, the number of
nuclear families dropped from 39% of all households in 1968 to 28%
in 1992.

What are the other family structures that could exist? There are
certain family units which function as families but do not conform to
the traditional family structure.

Groups of individuals could live together as a family –

Examples are :- Unmarried sisters living together
Adult couples who are cohabiting
A single parent (married, divorced or separated)
with a child or children
Brothers and sisters living together with an
adopted child

What are the basic functions of a family ?

The basic functions of a family are

* Socialization - development of interpersonal relationships.
Eg. the new born baby makes eye to eye contact with the mother
and smiles. This is the learning of social skills and development
of interpersonal relationships between members of the family
who are of different ages.
* Support and nurturing of family members - provision of
food, shelter, warmth and protection.
* Affection between family members, love, caring and concern.
* Legitimization of sexual relationships and procreation
* Security which is influenced by educational, occupational and
socio-economic factors.

Therefore, the family gives its members a sense of belonging such as

affection, companionship and security. The family is also a source of
advice and help. Family membership implies a lifelong commitment
with no option to leave. One can never totally deny or say that one
does not belong to one’s parents, siblings or children.

Family roles

Different members of a family have different roles to perform. The

traditional role of the different members of a family could vary
between different cultures. In most cultures the wife is expected to
be the home maker and mother, while the father is expected to work
for a living and be the breadwinner. The child’s role in a family is a
more passive one - receiving the attention of parents and siblings and
all the time learning and practicing new skills.
The father is also the ultimate authority in decision making although
this may vary depending on the particular family and culture. In
modern times, the traditional role of husbands and wives have
changed, specially in the West where wives are also working and the
husbands share in the housework and nurturing of children. In some
countries, fathers are given paternity leave to take care of the new
bom baby. Roles may sometimes be completely reversed eg. house
husband and career woman. Even in Asia, traditional roles are slowly
changing, with more and more women going to work outside the
home to supplement the family income. Many women go overseas
leaving the husband and the extended family to look after the
children. These changes in the traditional role, could bring about
many complex psychosocial and medical problems in families, and
the family physician should be aware of these, in order to provide
comprehensive and personalised care to patients and their families.

The Individual and the Family Life Cycle

For the family physician to give proper care to individuals and

families, he or she needs to have a knowledge of the human or
individual life cycle and the family life cycle. This is necessary
because the family physician sees patients and their families at
different stages of the individual and the family life cycle.
Knowledge of the stages in the life cycle, would help the family
physician to recognise and anticipate problems before they arise. The
doctor could then provide anticipatory guidance and preventive
counselling before problems arise and treat and effectively manage
problems that have already arisen.
Human Life Cycle or Individual Life Cycle

1. Pre-natal period
2. Infant
3. Pre-school child
4. School child
5. Teenager or adolescence
6. Early adulthood
7. Mid-life crises
8. Middle adulthood
9. Retirement
10. Dependent elderly

Family Life Cycle

1. Married couple without children

2. Child bearing families (oldest child between 0-30 months)

3. Families with pre-school children (oldest child between 30

months – 6 years)
4. Families with schoolchildren (oldest child between 6-13 years)

5. Families with teenagers (oldest child between 13-20 years)

6. Families launching young adults (first child gone to last child

leaving home)

7. Middle aged parents – empty nest to retirement

8. Ageing family members (from retirement to death of one or both

spouses)

Fig. 1 The Family Life Cycle (Duvall 1977)

(Adapted from McWhinney lan R. A Textbook of Family
Medicine. Oxford University Press 1989.)

A model of a family life cycle is shown in Fig. 1. Although

developed by Duvall to describe the eight stages through which a
typical American family goes through, this model with some
modifications could also be applied to families in other cultural
settings.

The different stages could be described as normal developmental

stages in the family life cycle. Each stage has certain tasks with
happiness and contentment mingled with problems and difficulties
that are unique to a particular period of time in the life of a family.
Since these are normal experiences of the majority of families, the
problems and difficulties experienced by families could be
considered as ‘normal stressors’ for that particular stage of the life
cycle.
The first six stages of the individual life cycle more or less
correspond, to the first six stages of the family life cycle.

The pre-natal period which is the earliest stage in the development of

an individual is the most dramatic period of physiological
development. The family at this stage will also be in the first stage of
its development, a married couple without children.

The mother will feel the foetal movements and the couple may have
to adapt to certain psychosocial changes. Parents will have a strong
desire to prepare the home for the new baby called “ nesting”. Pre-
natal counselling of the couple by the family doctor, may be
necessary in preparation for the new baby.

The next stage is when the baby is born and mother infant bonding
takes place with the initiation of breast feeding. The infant learns to
socialise and smile at 6 weeks. The infant will next go through the
normal milestones such as turning over, sitting up, walking and
talking. During this period, the family will be at stage two. The
parents will have concerns about the baby’s crying and sleeping
patterns, feeding problems, toilet training, separation anxiety and so
on. At this stage, counselling by the family physician may be
necessary for the parents to be educated as to what is normal and
what is abnormal with regard to their baby’s behaviour.

In the pre-school period, which is the next stage in the development

of the individual and the family life cycle, the child may have
behavioural problems such as anorexia, thumb sucking, temper
tantrums, breath holding attacks etc. The child is also vulnerable to
infections and if the diet is not adequate, the child may get
malnourished. This stage is also a period where parents will be
thinking of the child’s schooling. This could be considered a ‘normal
stressor’ for parents at this stage of the family life cycle.

The same problems of the pre-school child could extend into the
stage of the school child. Eg. infections, behaviour problems etc. The
child is also more prone to trauma and accidents. It is the duty of the
family physician to immunize the child, treat infections, monitor the
child’s growth, give advice to the parents and provide anticipatory
guidance and preventive counselling with regard to accidents.

The next stage is the teenager or adolescent. The normal stressors for
the teenager are, difficulties in adapting to the physiological changes
of puberty and the emotional changes of growing up and becoming
independent. Due to the influence of peer pressure they may
experiment with drugs, alcohol and sex. In the process of becoming
independent, conflicts may arise with parents. The parents at ages
between 35-45, would be in stage 7 or the midlife crises stage of the
individual life cycle, when they may be facing career changes and
marital crises. With problems posed concurrently by teenage
children, this may be a very turbulent period for the family at stage 5
of the family life cycle.

The next stage in the individual life cycle is early adulthood, where
personal goals such as choice of a career and choosing a marriage
partner could be considered as normal occurrences. This corresponds
to stage 6 of the family life cycle where the family is launching
young adults. The parents would be facing middle adulthood (50-60
years) and may be at the height of their respective careers. The
mother may also be facing physiological changes of the menopause.

This is soon followed by the retirement stage and the empty nest
stage in the individual life cycle and the family life cycle
respectively. The stage of retirement for the individual is usually
associated with having to adapt to a new life. They may also have a
chronic disease or disability at this stage. The loneliness and
depression felt by the parents when all the children have left home is
described as the ‘empty nest’ syndrome. This is a normal stressor,
which occurs at this particular stage of the family life cycle and
recognition of this and appropriate counselling by the family
physician is important.

The final stage in the individual life cycle is old age, with disabilities
associated with poor vision and hearing, inability to get about,
increasing dependence on the family and readiness for death. The
corresponding stage of the family life cycle is ageing family
members to death of both spouses.

When caring for patients and their families, the family physician
should be sensitive and be aware of the developmental stages of the
life cycle and the associated family dynamics at the different stages.
Although considered as normal occurrences at a particular stage of
the life cycle, there are families that adapt successfully to these
‘normal stressors’, while there are other families that are unable to
adapt. Families that cannot cope or adapt may become dysfunctional.

A caring family physician would be able to place the patient at the

correct stage of his or her life cycle, be aware of the likely stressors,
anticipate problems before they arise and provide anticipatory
guidance and preventive counselling. Where a problem has already
arisen, he or she should be able to counsel the patient and family to
prevent further family dysfunction from taking place. One of the key
aspects to health maintenance would be for the family physician to
identify and manage developmentally linked health and psychosocial
issues that arise at the different stages of the individual and family
life cycle.

Unexpected life events

In addition to the normal events which occur, unexpected life events
could also occur at any time and these would impose further stress
on the family. Eg. unexpected death of a family member, separation
or divorce, loss of job or change in job or problem at the work place,
change of residence, problems with in laws, family member
migrating to another country and so on.

The Family in Disease

There are two aspects to be considered. The impact of disease on the
family and the impact of the family on disease.
The family could be the source of a health problem and it is also the
most important resource to solve a health problem.

The family as the source of health problems

The family could be the source of a health problem, illness or

disease. Certain illnesses and diseases tend to occur in families.
These could be physical illnesses, psychosomatic disorders and
emotional disorders.

Physical illnesses
Due to physical closeness, infectious diseases such as the common
cold, streptococcal infections, staphylococcal infections, scabies,
exanthemata etc. could affect all members of the family.
Families could be affected by malnutrition, diabetes, hypertension or
cancer due to having the same genetic predisposition and inherited
factors as well as the sharing of life style, environmental factors and
socioeconomic influences.

Psychosomatic disorders
Family problems such as alcoholism, marital problems etc. could
lead to psychosomatic disorders such as irritable bowel syndrome
and asthma in other members of the family. For example, where the
father is an alcoholic or parents are having marital problems, a child
could develop asthma.

Emotional disorders
Anxiety, depression, behaviour problems could arise as a response to
a death in the family, chronic disease in a family member, divorce
etc. When parents are going through a divorce, the child may
develop a behaviour problem such as bed wetting or aggressive
behaviour which is called ‘acting out’. Following the death of a
spouse, the remaining partner could develop depression. A chronic
disease such as schizophrenia or AIDS in one family member could
lead to anxiety or depression in other members of the family.
The impact of disease on the family
When a chronic illness affects one member of a family, the family as
a whole has to adapt to the disease in the patient.
They have to adapt to
* medical treatment and hospitalization
* uncertainties of crises and possibility of death
* changes in the patient’s behaviour and appearance
* patient’s dependence on the family for care

If the family has sufficient resources to cope with the above stresses
produced by an illness in a family member, they would be able to
adapt and cope successfully. The resources needed may be
psychological strengths of the family members and financial
resources to cover the cost of medical treatment. In addition, social
support from extended family and friends is also essential. If
resources are available, the family would adapt successfully and
function well. If the resources are insufficient, family distress may
appear in the form of somatic and psychological symptoms in the
patient and members of the family. The outcome would be a
dysfunctional family.

The Family as a resource to solve a health problem

When one member of the family falls ill, the family physician will
call upon the other members of the family to care for the sick person.
The family physician should be able to counsel the family. He should
recognise the family unit’s potential for solving its own problems
and place the illness and the person in a context which allows the
family to use its own strengths to solve the problem.
A therapeutic triangle often exists between the physician, patient and
family although they may not be aware of it. The family physician
could use this triangle to improve communication and understanding
between the patient and family members and improve the delivery of
health care. While relating to each member of the family, the family
physician should take care to adopt a neutral stance and maintain
confidentiality with individual members of the family.
Family systems assessment tools
1. Family genogram
2. Family circle
The family genogram although not necessary for every family, is one
that is drawn by the family physician when there is a need to identify
inherited disorders and potential health problems for which
preventive care could be taken. It is also useful in identifying
disturbances in family relationships that have given rise to family
dysfunction. The family genogram contains factual information
about the patient and family including the past medical history and
other major events. It is a three generational family tree which
outlines ages, birthdays, marriages, divorce, chronic disease and
deaths as well as interpersonal relationships. The details of how to
draw and interpret the family genogram are given in detail in
Chapter 17.

The family circle is a simple technique for gaining information about

relationships. It should be explained to the patient that this tool is
used to help the family physician understand the patient and family
better, in order to help them with existing relationship problem/s.
The family physician draws a large circle to represent the family and
requests the patient to draw smaller circles or shapes within or
outside the circle to represent people who are important to him or
her. The drawing facilitates the patient’s self awareness to his or her
problem as it is the patient who interprets it. The family circle
emphasizes the patient’s perspective of the family system and social
network and can be quite emotional for the patient.

The doctor may be able to assess the degree of closeness of

relationships or animosity within relationships or people outside the
family who are of special significance to the patient. The doctor
could then discuss these issues with the patient with the goal of
helping the patient to bring about desirable change.
Levels of physician involvement in family oriented care

The degree to which a family doctor gets involved with a family

varies between consultations and from doctor to doctor. Five levels
of physician involvement with families have been identified. The
higher levels require more knowledge and skills as well as time on
the part of the physician.
1. Minimal involvement - Physician gathers biomedical data,
makes a diagnosis, treats the illness and sends the patient
away.
2. Considers the family as a partner in care and discusses the
medical findings, treatment options and explains the
prognosis to family members.
3. Both above + understanding of the emotional aspects of
family relationships. The doctor could provide psychological
support and help family members deal with feelings aroused
in them, by critical illness in one member. To do this, the
family physician should have prior knowledge of how the
family reacts to stressful experiences. He or she should be a
good listener and be able to respond to verbal and non verbal
cues by which emotional needs are expressed.
4. Systematic assessment of family function and conduct a
family conference or family meeting. This is called primary
care family counselling which may take place over one or
several visits. The physician’s goal is to act as a catalyst and
help families to cope more effectively with stress of a family
problem or stress caused by an illness in one member of the
family. The family will work on its own to bring about the
necessary changes to solve the problem.
5. Family therapy - planned course of therapy for a
dysfunctional family.
Most doctors function only at levels 1 & 2. Probably medical officers
in outpatient departments function only at level 1 due to the shortage
of time available for each patient. Most family doctors would
function at levels 2 & 3.
Family focused physicians would also function at level 4, in which
the doctor would conduct a family meeting or family conference.
The family meeting may occur naturally during a consultation when
the patient is accompanied by one or more members of a family. It
could take place when some members of the family have returned
from abroad to solve a problem affecting the entire family due to an
illness in one member of the family. A family meeting or conference
could also occur spontaneously during a home visit. A family
meeting may also be a planned one initiated by the doctor and
arranged by prior appointment so that as many members of the
family could participate Common reasons for having a planned
family conference include the following:-

* To develop a plan of care for a patient following discharge

from hospital
* To help the physician understand the psychosocial issues
surrounding a patient’s illness
* To develop a treatment plan after negotiating with the family
for a problem such as cancer or a stroke in one member of the
family
* To help family members cope more effectively with a chronic
illness in a family member

Family therapy at level 5 for which special training is necessary, is

usually undertaken by physicians who have undergone training in
family therapy. In family therapy, the aim is to change the way in
which the family functions. The family therapist finds it easier than a
family physician to do this, as the therapist has no continuing
commitment to maintain the health of individual members of the
family. Therefore, family physicians rarely take to family therapy
because of ethical problems that could arise due to a conflict in their
role of caring for individual members of the family. However, they
could always refer the patient to a family therapist, if and when the
need arises.
 CHAPTER 11

DETECTION AND MANAGEMENT OF THE

SOMATIZING PATIENT

The training of medical students and doctors is focused on

identification and treatment of organic disease with little attention
being paid to somatization. Somatization is where patients present to
doctors with physical complaints for which an organic cause or a
disease cannot be found. It is important to understand the
phenomenon of somatization to effectively diagnose and treat these
patients.
The phenomenon of somatization, which results in unexplained
physical complaints, is extremely common in primary care settings
but often go unrecognized. It is pertinent to add that this could
happen even at specialist consultations in countries such as Sri Lanka
where there is no referral system and people have the freedom to self
refer themselves to any secondary or tertiary care specialist if they so
wish.
Somatizing patients have been found to account for at least one third
of all consultation in general practice / primary care. In fact,
according to one study no organic cause was found in 80 percent of
primary care visits for common symptoms such as chest pain, fatigue
and dizziness. Somatization is more common in females than in
males.
Somatization has been defined as a tendency to experience and
communicate physical symptoms in response to emotional distress
and stressful life situations, to attribute these somatic symptoms to
physical illness and to seek medical help. It is often associated with
psychiatric and psychosocial disorders such as depression, anxiety,
panic disorders, obsessive compulsive disorders, personality
disorders and substance abuse. The finding of such conditions do not
rule in or rule out somatization but provides a clue to the diagnosis.
There is evidence that patients particularly with anxiety and
depression often present to doctors with non specific somatic
symptoms and this is a very common presentation in Sri Lanka and
other South Asian countries.
Many doctors miss the presence of a psychological illness in
somatizing patients, request many investigations to exclude organic
disease, treat with unnecessary medications and make inappropriate
referrals to specialists. It is important for doctors to learn how to
detect and manage these patients as it would reduce the suffering that
such patients undergo, prevent 'doctor shopping for a cure' and make
medical care more cost effective.

Classification of Somatization
The patient with somatization was previously classified in the
Diagnostic and Statistical Manual of Mental Disorders (DSM IV)
and the International Classification of Diseases (ICD 10) under the
term undifferentiated somatoform disorder. This term has been
replaced by Somatic Symptom Disorder (SSD) in the latest DSM -5.
An SSD diagnosis does not require that the somatic symptoms are
medically unexplained which was a key feature in the diagnosis of
somatoform disorders in DSM IV. The new SSD definition also
includes patients who have medical conditions such as co-existing
heart disease or cancer but have somatic symptoms that are out of
proportion or excessive to the medical condition
A summary of the diagnostic criteria for SSD as given in DSM – 5
include the following:-
One or more symptoms that are distressing or result in significant
disruption of daily life together with excessive and persistent
thoughts, feelings and behaviours about the seriousness of the
symptoms which take up time and energy leading to a high level of
anxiety that typically lasts for 6 months.
These criteria are relevant for the diagnosis of SSD in patients seen
in actual clinical practice by general practitioners / family physicians
or specialists in disciplines other than psychiatry. What family
doctors often see in family practice is the milder form of the disorder
where there may be only one persistent symptom and the duration
may be shorter than 6 months although the severe disorder fitting
into the strict diagnostic criteria given in DSM – 5 are also seen.

Pathophysiology of Somatization or somatic symptom disorder

The pathophysiology or psychological mechanisms involved in

somatization are described below.
a) amplification of normal body sensations and physiological processes
that are interpreted as abnormal eg. worrying about a disease may
make a person focus on a particular organ, for example the heart. In
doing so a patient may interpret normal body sensations such as the
normal heart beat as being abnormal. Worry about heart disease
would lead to palpitations which is a physiological process and this
will reinforce the patient’s belief that he or she has indeed something
wrong with the heart and patient may end up seeking medical care
for the palpitations.
b) a person who has knowledge and understanding about a certain
disease after reading articles in newspapers or seeing it on the
internet may interpret minor pathologies in themselves such as a
lymph node that has been there for a long time as being a sign of
leukaemia or TB and consult a doctor about it.
c) a person who gets emotionally aroused on hearing that a relative had
suffered from a stroke, may after sitting in the same position for a
long time, experience a numbness in his leg that he interprets as
being abnormal and thinks that he too is coming in for a stroke and
seek medical advice.
d) a person may develop physical symptoms due to the need to be sick
in order to get relief from stressful situations (primary gain) and to
receive more care, attention and sometimes even monetary rewards
(secondary gain). Because the patient cannot send the symptoms
away willingly, such a patient is not malingering (deliberately faking
the symptoms) but is genuinely suffering from the symptoms.
The four mechanisms explained above results in physical symptoms
which lead to behavior change and consequent disability.

Why do somatizing patients present to doctors with somatic

complaints rather than psychological symptoms?

Patients with somatization, anxiety and depression suffer from both

somatic symptoms and psychological symptoms. Physical symptoms
may include palpitations, chest pain, headache, abdominal pain,
backache, joint pains, dizziness, difficulty in breathing, weakness of
the body etc. with pain in some part of the body often being the main
complaint. Although emotional symptoms such as irritability,
anxiety, sadness, insomnia, poor concentration and excessive worries
 about the symptoms may also be present, somatizing patients
complain of only the physical symptoms to the doctor as their reason
for coming. However, there will be some patients who will offer
verbal or non verbal cues to the presence of a psychological cause
for the illness during the consultation. Doctors who are sensitive to
these cues and the underlying anxiety of the patient will be able to
easily detect the somatizing patient.
The reasons for presenting the physical symptoms first is because
many patients are concerned that such symptoms could be the sign of
a heart attack, stroke or cancer and want the doctor to reassure them
that the symptoms they have are not due to a serious disease. Some
may feel that psychological symptoms are not relevant to their
condition although they have such symptoms. Patients may also not
have the necessary words to describe their emotional symptoms in a
meaningful way.
Patients also tend to believe, that doctors expect patients to present
with physical complaints and are not interested in their psychological
symptoms. Since the majority of doctors have had most of their
training in the diagnosis of organic diseases, they tend to reinforce
this type of help seeking behaviour.

How can doctors improve their skills in detecting these patients?

The cornerstone for detecting these patients is good communication.
Certain pre-requisites are necessary for good communication. The
doctor should -
 have humane values and attitudes towards patients and
relatives.
 have a belief in the biopsychosocial model of disease which shows
the close relationship between the mind, body and environment
unlike the pure biomedical model.
 be prepared to provide whole person care directed at a patient’s
physical, psychological and social well being.

Good communication means that the doctor should………

 Listen to the patient. Listen with concern, have good eye contact
with the patient and use a tone of voice that shows interest and
concern. Actively listening to the patient in this way will allow the
patient to express himself or herself freely. Listening to the patient
 for a minimum of one and a half minutes without interrupting will
help to elicit useful information in detecting somatizing patients.

 Be aware of verbal and non verbal cues. Verbal cues are what the
patient says and non verbal cues are what a patient is communicating
through his or her behaviour. Quite often doctors miss verbal cues
such as when an elderly woman says ‘ I have been unwell since my
husband died’. Non verbal cues to look out for are a sad facial
expression or a worried look.

 Another pointer to a psychological illness is where multiple

complaints involving different parts of the body are presented by the
patient which do not fit into a known organic disease. These are
referred to as medically unexplained symptoms.

 When questioning the patient, the doctor should first ask open ended
questions or make statements that will help to diagnose a
psychological illness such as somatization or depression or anxiety.
If a doctor asks closed questions first he will only get ‘yes’ or ‘no’
answers from the patient and nothing else.

The doctor could use the following open ended questions or

statements to help elicit a psychological problem:-
- Could you tell me more about your illness?
- It seems to me that you are rather unhappy today.
- You appear to be anxious about something.
- Is there anything else that you want to tell me?
- What is it that you are afraid of?
- How does this illness affect your day to day life?
- What is it that you are unable to do as a result of this
illness?
- What do you think is the cause of your illness?
- What made you come and see me today?

The doctor could also convey empathy to the patient. Empathy is

where you show the patient that you understand what the patient is
going through. Imparting empathy requires ‘putting yourself in the
patient’s shoes and experiencing the feelings that arise”. Empathy
could be conveyed non verbally through a kind facial expression and
a tone of voice showing concern and verbally by making statements
such as the following:-

"It must be a very difficult for you to have to bear with the pain of
your arthritis while having to look after your invalid mother”
"Your son being at the war front must be a great strain on you."
"Hearing that your child had fallen ill at school must have made you
awfully worried"
Patients quite often respond to this form of communication and start
to cry and tell all their problems to the doctor. The doctor’s complete
attention and empathy conveyed to the patient leads to the
establishment of a positive therapeutic alliance in the physician-
patient relationship that is essential to effectively diagnose and treat
these patients. (Rogerian paradigm)

Once a positive therapeutic alliance has been established, the greatest

challenge the doctor has to face is to exclude a medical condition
that may manifest similar symptoms. To exclude a medical
condition, it is therefore important that the doctor does a relevant
physical examination to show the patient that his or her symptoms
are being taken seriously. Also the doctor cannot reassure a patient
that there is no organic disease unless at least a brief clinical
examination has been done.

In some instances a few basic investigations may be needed as well.

The important thing is to keep the investigations to a minimum.
Ordering too many tests will only reinforce the patient's neurotic
behavior and make him or her believe that there is indeed something
seriously wrong. Telling the patient that all the tests are negative, that
there is nothing wrong and sending the patient away with a placebo
is also not good as this will only reinforce the patient’s belief that he
or she is suffering from such a serious disease that even the doctor
cannot diagnose.

The coincident presence of a chronic disabling medical condition is

also a possibility and does not exclude somatization. When the
symptoms appear to be in excess of the medical condition and other
features of somatic symptom disorder are present, the physician
should address somatization in addition to appropriate work-up and
 treatment of the medical condition.

Therefore in summary, evaluation of somatization in primary care is

to make a positive diagnosis of somatization or SSD combined with
evaluation for the presence or absence of concurrent organic disease
and evaluation for psychiatric conditions such as depression, anxiety
disorders or substance abuse that may co-exist.

Diagnosis of the somatizing patient –

It is important to make a positive diagnosis of somatization or SSD
when a patient presents with typical features. A significant pointer to
SSD is that the intensity of the symptoms is out of proportion to the
healthy appearance of the patient. It is also important to bear in mind
that many patients the family physician comes across in actual
practice may not have all the features of an SSD and will be milder
cases of somatization. The role of the family physician is to detect
these patients with minimal features early in the illness and treat
them adequately to prevent them going to the severe form of the
disorder.

How should the family physician manage the somatizing patient?

 Explain the pathophysiology of the symptoms to make the patient
understand the nature of his illness and reassure that the symptoms
are not due to a serious disease.
 Refer for cognitive behavior therapy (CBT) to reduce the
intensity and frequency of somatic complaints as CBT could help
change the patient’s negative thinking and maladaptive behaviours to
more positive thoughts and appropriate behaviours.
 Prescribe an anti anxiety drug if necessary for a short period (not
more than 2-4 weeks).
 Offer general advice on stress management such as engagement
in pleasurable activities that help in relaxation, life style changes eg.
physical exercise and problem solving and social skills. Other stress
management techniques such as yoga and meditation have been
shown to be extremely useful.
 Give advice on handling of interpersonal relationships and conflicts
eg. marital conflicts.
 Allow patient to use methods for cures they believe in although
there may not be much evidence for them such as local application of
 lotions and ointments, bandages, ice packs, vitamins and nutritional
supplements, acupuncture, massage therapy etc.
 If the patient is taking multiple medications, tail off the unnecessary
drugs as this has been shown to result in marked improvement of
symptoms brought about by side effects of drugs.
 Enter into a contract with the patient by arranging follow up
visits on a regular basis so that the patient does not need to produce
new symptoms to consult the doctor.

In spite of all of the above measures, somatizing patients are difficult

to treat and there could be many pitfalls during management.
Problems in management include frequent telephone calls,
admissions to emergency departments, presence of co-morbid
conditions, demand for more diagnostic workups, and requests for
strong and addictive drugs. A caring family doctor who has
established a trusting physician patient relationship and who spends
sufficient time listening to the patient and giving explanations would
be able to deal with these difficulties and reduce the suffering of
somatizing patients and hopefully reduce the cost of medical care.

Chapter 12

COUNSELLING AND SUPPORTIVE

PSYCHOTHERAPY

Counselling is an integral component of quality patient care in

general practice.

The aim of counselling is to enable a person to respond more

effectively to his or her situation, where a change in the behaviour of
the person or a change in the environment needs to be brought about.

The counsellor acts as an integrator and helps the person to do some

self exploration to discover for himself or herself what best to do in a
particular situation.

In family practice, the family physician is the counsellor to the

patient and his or her family regarding a range of problems such as
the following –

* Behaviour problems in children

* Psychosocial problems
* Psychosexual problems
* Alcoholism
* Drug addiction
* Marital problems
* Family Planning
* Unwanted pregnancy
* Terminal illness and bereavement

* Chronic illnesses like diabetes, hypertension & bronchial

asthma
* Obesity
* AIDS

To counsel effectively, interviewing skills are important. These

include the establishment of rapport by greeting the patient, listening
to the patient with interest and concern, maintaining eye contact with
the patient etc. To be a good counsellor, the doctor should be able to
show empathy.

Empathic understanding means that the doctor will try to understand

the patient both verbally (what the patient is communicating through
the spoken word) as well as behaviourally (what the patient is
communicating through his or her behaviour). This is sometimes
described as listening with the ‘third’ ear.
Other interviewing skills that are useful in counselling are
 * Reflect back to the patient what he or she has said to clarify a
point
* Use silence to allow patient to express emotion
* Try to understand what the patient is feeling
* Observe lack of congruence
* Offer supportive comments
* Prompt the patient
* Summarise what the patient says

Stages in the counselling process - The 5 E’s :

1. Establishment of rapport
2. Exploration - find out the patient’s problem mainly by listening
- an atmosphere of trust and confidentiality should be present.
3. Examination - help the patient to understand the problem and
realise the need for some action on his or her part to solve the
problem. Help the patient decide what personal and
environmental factors need change.

4. Elaborate on action - work out a plan to solve the problem,

find out what resources and alternatives are available, weigh the
available alternatives and discuss the implications of these
alternatives.
5. End - Allow the patient to select his or her own course of action
and implement it. The final decision is made by the patient and
family and not by the doctor.

Ethics in Counselling

* Confidentiality is essential
* Case Recording - only a summary should be written down and
this should only be accessible to the doctor.
* Competence is important. If the doctor is not competent in
counselling a particular problem, the patient should be
referred to a professional counsellor in that field.
* Counselling should not be undertaken by the doctor if the
 patient is a family member or if there is a social relationship
with the patient.

What a Counsellor should and should not do

Doctors who are counselling should have genuine concern for the
patient, listen and show empathy and should always be aware of the
family context. Confidentiality should be maintained individually
with each member of the family.

Counsellors should be able to handle and monitor their own feelings

and be comfortable with what the patient is saying.

Doctor who is counselling should be aware of his or her own cultural

values and attitudes and not let these get in the way of the
counselling process. Doctor should give factual information when
necessary.

The counsellor should be non judgemental and impartial and should

refrain from expressing judgements either verbally or non verbally.
Only exception would be in a situation where the patient’s proposed
course of action may seriously harm the patient or others. For
example, a patient who is contemplating suicide or a patient with
uncontrolled epilepsy who insists on driving.

Supportive Psychotherapy

Unlike professional counsellors who are lay people, a doctor who

counsels can give supportive psychotherapy as well. Family doctors
are in an ideal situation to do this, due to the existing long standing
doctor-patient relationship through many years of continuity of care.
Therefore, in addition to counselling, the doctor could give
supportive psychotherapy. This may include;
a. advice
b. reassurance
c. suggestions to help the patient restore his or her coping
mechanisms
d. encouragement to get over the symptoms by giving support
 while allowing the patient to take responsibility for his or her
own recovery.
e. prescription of a placebo to satisfy patient expectations

Though counselling and supportive psychotherapy take a longer time

than prescribing a packet of pills or a bottle of medicine, doctors
should find the time to do it, because it forms an integral part of the
healing art in Family Practice.

Chapter 13

THE CONSULTATION WITH SICK CHILDREN

AND THEIR PARENTS

Paediatricians and family doctors need to develop special skills in

communicating with sick children and their parents. The skills of
communication and clinical examination may vary depending on the
age of the child.

When a child is brought into the consultation room, the feelings of

the child could be one or more of the following:-

The child is very frightened as to what is going to happen.

The child may be in pain due to the illness.
The child may be tired after having waited a long time in the doctor's
waiting room.
The child may be hungry, thirsty or sleepy.

The doctor may be tired too, but it is important for the doctor to
understand the child's experience of the illness and show kindness
and careful attention when talking with and examining the child.

Establishment of rapport and talking with the parents and the

sick child

It is important to establish rapport by greeting the parents and the

child. Most often it will be the mother who has brought her sick
child. The family doctor should encourage the mother to first give
the reason for coming to the doctor. The doctor should listen
attentively to the mother while showing an interest in the child.
Establishing good rapport with the mother is important to convey to
the child that the doctor is quite a safe person to be with. If it is an
infant, direct eye contact with the baby is best avoided initially.
Showing an interest in an older child such as admiring the dress the
child is wearing or by just saying hello will instill confidence in the
child that the doctor is a friendly person and not someone to be
afraid of.

Remember that the child is the star of the show. Not the mother or
the father or the doctor. Therefore the doctor could ask the child of
school going age whether he likes school, about his teacher or
friends at school and so on. If the child shows an interest in the
doctor’s equipment such as the stethoscope for instance, the doctor
could ask ‘do you want to become a doctor when you grow up?' In
this way the doctor can build up a good rapport with the child. It is
essential that little toys and games are kept in the consulting room to
show children that the doctor cares about them and want them to be
happy. Toys will also be quite useful to distract a child whose
abdomen or ear is being examined.

While taking the history from the mother, it would be useful to

observe the child to see whether the child is dyspnoeic or lethargic or
in pain. In addition to asking the mother about what is happening to
her child, the doctor could also ask the child who is of a reasonable
age about his discomfort or pain. Simple questions such as 'does
your throat hurt?' or 'does your ear hurt?' may be well understood by
a 3-4 year old. Listen to what the child says carefully.

When dealing with a child who is at an age that he or she can

understand what is happening, details about the illness should not be
discussed in the presence of the child. For example if the prognosis
is not very good or if the child has a behavior problem such as bed
wetting or thumb sucking or aggressive behavior, it would be
prudent to send the child out of the room with one of the parents
while the doctor talks with the other parent. However, where only
one parent has come with the child, the doctor could use his
discretion and make some arrangement for the child to be occupied
with a toy or a book until he completes the discussion with the
parent.

Communication during examination of the sick child

Examination of a child should not be rushed. A child who is

examined while being seated on the mother's lap will be less
frightened and cooperate with the doctor better. The least intrusive
of examinations should be carried out first, keeping the more
traumatic examinations to the last. Taking an example, if a child is
brought for a respiratory infection, examination of the lungs should
be done before examining the ears and the throat examination should
be left to the last. If the child cries when the throat is examined, it
does not matter as the doctor would get a good view of the throat
while shining the torch. Examining the abdomen of a child who is
crying and tensing his or her abdomen is useless unless an attempt is
made to make the child stop crying and become cooperative.

During examination, a child should be handled gently and the doctor

should talk to the child while doing so. If the examination will hurt,
the doctor should be truthful and tell that it will hurt a little and to
tell the doctor when it does. A child who is being given an injection
should be warned that it will hurt a little while reassuring that it will
be over very quickly.

Reassuring the parents

When talking to the parent/s, it is again very important for the doctor
to show concern and be caring. Parents of sick children are far more
worried when children fall sick than if they themselves were sick.
Their feelings may range from
'what is wrong with my child?'
'am I responsible for my child falling ill?'
'why did this happen to my child?'
'will my child get better?'
'is it a serious illness?'
These questions and fears will be running through the parents' mind
from the time they decide to consult the doctor and while they are in
the consulting room. If the doctor has carried out his or her duties
well, in most instances these fears would be allayed to a certain
extent when the parents leave the consultation room with their child.
It is important for the doctor not to blame the parents if they have
done something wrong with regard to the child's care. Except in the
very rare instance of child abuse, the great majority of parents will
never do anything willingly to harm their child. Therefore if the
doctor blames them unfairly, it could be very traumatic for the
parent.

When the time comes to discussing management with the parents,

the doctor should pay his or her full attention, show empathy and
explain in a language that the mother will easily understand. The
mother has many things on her mind when she is in the consulting
room and may not absorb everything the doctor is saying to her.
Therefore, in addition to telling the parents how to give the
medication to a child, writing the instructions on the back of the
prescription will be very useful. The parents should be warned about
danger signs to look for which may need another visit to the doctor
or the hospital. Parents should also be warned about common side
effects and what they should do if they occur. The parents should be
reassured but the reassurance should be realistic. If a child is referred
for admission, the parents and the child who can understand should
be told what to expect in hospital.

A caring family doctor will always let the parents know that he or
she could be contacted in an emergency so that giving the doctor’s
telephone number is useful. It is the family doctor’s duty to be
available and accessible to parents when undertaking treatment of
children with illnesses and specially where the condition could
change for the worse.

Family problems and the sick child

It is important for doctors to observe the parent-parent and child-

parent interaction which will give an indication that all is not well
with the emotional status of the child and the family. In his book
'The Doctor, The Patient and his Illness' Michael Balint states that, of
all children brought to the doctors surgery, it is only in one third that
the child alone needs treatment, in one third both parents and child
need treatment and in the remaining third only the parents need
treatment. Another concept put forward by Balint and his research
group of general practitioners more than half a century ago is true
even today of ‘the child being the presenting complaint’ of
interpersonal conflicts and problems within the family. The
knowledge of problems in the family may be useful for management
of the child's illness, so doctor’s need to be aware of them.

Promotion of health, preventive care and follow up care

When carrying out consultations where the focus is on the child who
is sick, the family doctor should ensure that during the index
consultation itself or during follow up, health promotion and
preventive care activities are carried out such as monitoring of
growth and development, age appropriate immunization, advice on
feeding, nutrition and behavior problems, aand anticipatory guidance
on prevention of home accidents etc. The cring family doctor is one
who would do all this as matter of routine and spend sufficient time
to do so.
 Chapter 14

CARE OF THE ELDERLY

The elderly

The age of 60 or 65 years, roughly equivalent to retirement ages and

pension schemes in most developed countries, is said to be the
beginning of old age. The UN has not adopted a standard criterion,
but generally use 60+ years to refer to the older population. In Sri
Lanka, according to the Annual Health Bulletin 2012, the proportion
of elderly persons in the population was 12.3%. Applying this to the
estimated population of 20.5 million in 2013, the number of elderly
people in the population would be around 2.5 million.

Life expectancy at birth has been increasing gradually since the

1950s. According to the Annual Health Bulletin, life expectancy at
birth in 2011 was 70.5 for males and 79.8 for females. Thus, with
better health care, more people are living longer and it is envisaged
that there will be a substantial increase in the elderly population in
the 21st century. It is important therefore for health policy planners
to improve geriatric health services to deal with the ageing
population in the future. The ‘One day general practice morbidity
survey’ carried out by the Faculty of Medicine, University of
Kelaniya in 1996, found that the proportion of the elderly in the
consulting population was significantly higher than that in the
general population. The fact that GPs are seeing a large number of
elderly patients, also makes it necessary, to give more emphasis to
the care of the elderly in family medicine teaching in medical
undergraduate and postgraduate curricula.

Unlike younger people, the elderly have special problems and need
special care.

Retirement

In the human life cycle, middle adulthood between 50-60 years is

followed by retirement at approximately 60 years of age. When a
person who has led an active life retires, perhaps at the height of a
fulfilling and successful career, he or she may experience a sense of
loss or loss of identity as the need to go to work everyday is not
there. In addition to the loss of identity, such a person may also
have to manage on a reduced income, unless there is an adequate
pension or a provident fund. Both the loss of identity and the reduced
income leads to a feeling of insecurity. Perhaps by this time, a son or
daughter may have replaced the parent as the head of the household.
On the other hand a retired couple whose children have left home
may be experiencing the empty nest syndrome. In addition to the
retired person having to put up with these psychosocial effects, there
will be the physiological effects of ageing as well as multiple
medical problems to cope with.

It is important for the family doctor to recognize what happens to

people when they retire and should be prepared to counsel such
patients on the need to continue an active life as far as possible. The
retired person could be advised to take up hobbies such as reading or
gardening, take part in recreational activities and engage in religious
activities.

The transition from retirement to old age at 65 years is a gradual one.

The transition from 65 years to the elderly dependent stage is also
gradual. Therefore, rather than lumping together all people who have
been defined as old, studies by gerontologists have recognized the
diversity of old age by defining sub-groups. One such sub-grouping
is “young old” (65-74), “old” (75-84), and "old-old" (85+). The
young old (between 65-74 years) specially in developed countries
are able to lead a fairly independent life. In fact, even in Sri Lanka,
some people in this age group help in looking after grandchildren at
home and age fairly late as they feel they have a useful function to
perform within the family. Over the age of 75 years, the onset of
dependency begins. At this stage there may be death of one of the
spouses. The over 75 year age group is usually concerned about
being dependent on others, becoming a burden to the family and
about death.

The changes that take place with ageing is a gradual process,

proceeding at different rates in different people. The changes are :-

1. Physiological effects of ageing

2. Medical problems
3. Psychosocial problems

Physiological effects of ageing

Skin - loss of elasticity --- wrinkles

Hair - baldness, greying

Teeth - decayed or lost

Eyes - cataract -- impairment of vision

Ears - age related hearing loss, wax

Bones – demineralisation -- osteoporosis

Joints – wear and tear -- osteoarthritis

Body build – reduction in height due to changes in the spinal column

Cardiovascular system – arteriosclerosis -- systolic hypertension

Genital tract - prostatic hypertrophy in males

- atrophic vaginitis in females

Sleep – reduced -- insomnia

Gastrointestinal tract – constipation
Urinary system – reduced renal function, nocturia, incontinence

Medical problems

Cardiovascular diseases - myocardial infarction, angina, atrial

fibrillation, stroke, hypertension,
congestive cardiac failure

Central nervous system diseases – dementia, parkinsonism

Psychiatric disorders – paranoid states, depression

Glaucoma

Diabetes

Renal failure

Prostate disorders

Hypo / hyperthyroidism

Cancers anywhere in the body

Psychosocial problems

Due to impairment of hearing and speech problems, the elderly could

have difficulty in communicating with people. Due to this, they may
be misunderstood and consequently become socially isolated.

Difficulty in moving about and going shopping or to the temple or to

the hospital, may also make them physically isolated and confined to
the home.

They may develop paranoid delusions and become suspicious of

family members, who may need education on this aspect of the
ageing process.
They may become forgetful, fail to take their medication properly
and slowly become dependent on others for most of their needs.

Consultation with the elderly patient

The consultation with the elderly patient could take place in the
doctor’s office, in the patient’s home and sometimes in the hospital.
The family doctor who is aware of all the problems and needs of a
geriatric patient, should be able to take a proper history, perform a
complete physical examination and make an assessment of the
patient’s physical, emotional and functional state. To make a proper
assessment of the patient may not be possible at the first encounter
and may need several consultations.

Establishment of rapport and a caring doctor-patient relationship

At the first encounter with an elderly patient, it is necessary to

establish rapport and provide the foundation for a caring and
satisfying doctor-patient relationship. A GP who is caring, who takes
time and shows a genuine interest will instill a sense of security in the
elderly patient who is fragile, lonely and insecure.

As the patient walks into the consultation room, the doctor should
notice the patient’s gait and whether he or she could walk unaided or
needs a walking stick. Sometimes the difficulty with walking may be
due to defective vision. Establish whether the carer / family member /
informant is to be interviewed jointly / separately.

Approach the older person with respect e.g. greet patient by surname
unless the patient indicates otherwise. In Sri Lanka, one may address
a female elderly patient as ‘Amma’ or an elderly male patient as
‘Seeya’ depending on the doctor’s age and the patient’s age.

Sit by the side of the patient rather than face the patient across the
table as the table would act as a barrier to good communication.
Ensure that the patient is comfortably seated and at the same eye
level as the doctor.

Sitting at a lower level than the patient with the light falling on the
doctor’s face would be less intimidating for the patient who could
respond to the doctor’s questions easily without feeling threatened
in any way. The doctor should be friendly, conversational, speak
clearly and go at the patient’s pace and allow sufficient time to
receive an answer.

Taking the history

When taking the history, attention should be paid to the following:-

1. Past medical history, diagnosis cards, results of investigations,

previous prescriptions etc. The patient's current medication and
any adverse effects of drugs should be taken note of, as these are
common in the elderly.

2. Assessment of the patient’s ability to communicate by

evaluating vision, hearing, comprehension, speech and the
mental status. Perhaps a general conversation on the reason for
the visit and asking the patient his or her date of birth or address
will quickly reveal cognitive impairment.

3. Eliciting the patient’s agenda by listening carefully to the

patient’s problem. An elderly patient may be more concerned
about constipation or insomnia than whether his blood pressure
is under control.

4. Assessment of the activities of daily living (ADLs)

5. Assessment of the Instrumental Activities of Daily Living

(IADLs). This includes the patient’s ability to get about such as
going to the hospital, ability to handle money, listen to the radio
or watch television.

6. Assessment of the emotional status, presence of depression or

cognitive impairment.

7. Ascertain whether family support is available or not.

8. Signs of neglect of the patient or abuse by the care giver or

family member should be looked out for.
A thorough assessment of ADL and IADL function are an integral
part of the geriatric examination as they are an indication of the
patient’s ability to lead an independent life.

Activities of Daily Living (ADLs)

a) Mobility – whether the patient needs help from another

person or a walking stick when moving about the house.
Whether the patient is confined to bed or a wheel chair.

b) Eating – whether the patient needs to have food specially

prepared due to problems with mastication and whether
help with feeding is required or not.

c) Washing and bathing – whether the patient needs help with

washing and bathing.

d) Dressing – whether the patient needs help with dressing up,

zippers or shoes etc.

e) Toileting – whether the patient can walk to the toilet or

needs a bedside commode or is incontinent.

Instrumental Activities of Daily Living (IADLs)

a) Transportation – Can the patient walk on the road, get into a bus
or drive a car?.

b) Money management – Can the patient handle money while

shopping, pay bills, do transactions in the bank etc?.

c) Meal preparation – Can the patient prepare his or her own meals,
is it done by someone else, who does the shopping for food
stuffs?

d) House work and washing clothes – Can the patient do these

activities?
e) Telephone use - Does the patient have a telephone, know the
phone numbers of close relatives and know whom to call in an
emergency?

f) Medication – whether the patient can take the medication by

himself or herself or whether supervision is needed.

Physical examination

The physical examination of the elderly patient in general practice,

should include a full clinical examination of all the systems. This is
necessary, because the elderly are more likely to suffer from co-
morbidities, some of which may remain undetected unless
specifically looked for.

Prior consent should be obtained from the patient before

examination. The doctor should explain to the elderly patient why an
examination is needed and what the doctor is going to do while
reassuring the patient that it will not hurt and will be done as gently
as possible. The patient’s privacy needs to be maintained at all times
and parts that are not being examined covered with an item of
clothing or a sheet.

The examination of the elderly patient should include the

following :-

* General examination – anaemia, ankle oedema, gait, nutrition.

* Weight – whether overweight or underweight.
* Ears –examine with the auroscope for wax, test hearing.
* Speech
* Vision – visual acuity, cataract, glaucoma.
* Teeth and gums – if using dentures, whether well fitting or not
* Neck - thyroid.
* Skin and nails
* Joints and spine.
*Abdomen – for lumps, constipation, haemorrhoids, impacted
faeces.
* Cancer – in any part of the body.
* Prostatic hypertrophy in the male and utero-vaginal prolapse in the
female
* Cardiovascular system – blood pressure, congestive cardiac
failure, atrial fibrillation. The blood pressure should be measured in
both supine and standing positions. The pulse should be counted
for a full minute to detect changes in volume and rhythm.
* Respiratory system – respiratory rate, whether dyspnoic at rest
* Functional disabilities - difficulty in walking, getting on to the bed,
rising from the chair etc. should be noted.
* Mental status examination - special attention should be devoted to
the mental status evaluation. Screening for early dementia or
cognitive impairment is important and the doctor may be surprised
to find that a co-operative and pleasant elderly patient is
disoriented and has a poor memory when tested. The mini-mental
state examination is useful for this purpose but needs to be
translated and validated for use in different cultural settings. The
translated and validated version is available for a Sri Lankan
elderly population (Gunatilake and de Silva 2000).

Laboratory investigations

Basic screening tests such as blood sugar, renal and liver profile,
ECG, X ray chest, urine for FR, ESR should be performed at least
when seeing the patient for the first time.

However, the doctor should be selective when requesting

investigations in the elderly patient. The potential benefits of a test
should be weighed against the potential risks, cost and inconvenience
of transporting and accompanying the elderly patient for a test. The
general principle should be, not to order a test which will not alter
the treatment. Routine screening using auto analysers which do
multiple tests may not be cost effective, as a false positive result
could lead to further unnecessary evaluation.

Common geriatric problems

 Sleep disturbances
  Muscle and joint pains
 Difficulty in communication and social isolation
 Ill fitting dentures and poor oral hygiene
 Poor vision and hearing
 Poor compliance with medical treatment
 Urinary and faecal incontinence
 Constipation
 Depression
 Dementia
 Adverse reactions to drugs
 Behaviour changes
 Frequent falls, postural hypotension
 Frailty
 Elder abuse or neglect
 Care giver stress

Of the conditions listed above, depression, dementia, behaviour

changes, frequent falls and presence of frailty should be evaluated
properly and may need specialist consultation or referral.

Depression may sometimes be masked by delusions and somatic

symptoms. Depression should be detected early and treated as the
elderly are prone to suicide.

Dementia Early symptoms include poor recent memory, impaired

acquisition of new information, inability to remember names,
personality change (withdrawn and irritable), tripping easily due to
visuo-spatial impairment and inability to perform sequential tasks.
Cognitive impairment could be detected by the mini mental status
examination. The symptoms are gradual in onset with continuing
deterioration and significant interference with social and work
functions. Delirium, other organic causes and major depression
should be excluded when making the diagnosis.

Behaviour changes other than due to dementia could be due to drugs

and alcohol, depression, deafness, visual deterioration, diuretic
therapy etc. Delirium in a stable elderly patient should alert the
doctor to the presence of infection, prescribed medication or drug
withdrawal. Delirium may be the only symptom of an infection and
the patient may not complain of pain or have fever. This is because
in the elderly, the pain threshold may be raised and there could be
disturbances in homoeostatic mechanisms that regulate the
temperature.

Falls in the elderly are common and could lead to injuries such as
fractures. Falls in the elderly should be carefully evaluated to
identify the underlying cause. The causes include transient ischeamic
attacks, postural hypotension in patients on anti-hypertensive drugs,
diabetic autonomic neuropathy, sensory impairment (visual,
vestibular), dementia and delirium, drugs (sedatives and alcohol)
environmental factors (tripping over something) or a combination of
one or more of these.

Frailty in the Elderly

Frailty in the elderly is conceptualized as a clinically recognizable

syndrome of older adults resulting from age-associated decline in
physiologic reserve and function across multiple organ systems
leading to increased vulnerability and difficulty in coping with acute
or everyday stressors.

With the present state of knowledge, no single operational definition

of the frailty syndrome or assessment tool has been agreed upon.
However, there is general consensus that frailty is a clinical
syndrome that indicates increased vulnerability to stressors leading
to functional impairment and adverse health outcomes. The frailty
syndrome may be reversible by interventions.

As proposed by Fried et al, Frailty is operationalized as a syndrome

meeting three or more of five phenotypic criteria: weakness, slowed
performance, low level of physical activity, exhaustion, and weight
loss. Where only one or two criteria are there, such patients are said
to be pre-frail while those with none of the criteria are non frail. This
definition also recognizes frailty as a distinct clinical entity as
separate from disability (impairment in ADLs and IADLs) and co-
morbidity (suffering from two or more diseases). However, there is
some overlap between all three conditions and when making a frailty
assessment, this must be borne in mind. All disabled persons are not
frail while all those who are frail are disabled. When chronic
diseases are present ( co-morbidity) which are not adequately treated
or when they worsen, the older adult may become frail. Both frailty
and co-morbidity are associated with adverse health outcomes such
as higher mortality.

Assessment of the geriatric patient

Once the doctor has made an assessment of the elderly patient’s

health and functional status, the doctor should concentrate not only
on diagnosing and curing diseases, but also on improving and
maintaining function. At a certain stage in the life of the elderly
patient, a decision will have to be made, that the goal of care is to
keep the patient comfortable, without resorting to medical
interventions that may not necessarily improve the patient’s quality
of life.

The outcome of assessment of the geriatric patient should include

establishment of a problem list, diagnostic issues and issues relating
to the proposed management.

Problem-oriented approach

A problem list in order of importance and from a bio-psychosocial

perspective should be made and the proposed manner of dealing with
the problems decided by the doctor in consultation with the family.

Diagnosis oriented issues

This may involve the steps that need to be taken to clarify the
diagnosis e.g. more information, investigations, specialist opinion.

Management issues

Successful management is based upon forming a therapeutic alliance

with the patient and usually their carer. The doctor should
communicate with the patient and carer in an empathic manner to
convince them that the doctor understands their problems and is
willing to work with them to resolve the same. In doing so,
communication of the possible diagnosis and proposed management
is essential. Possible management strategies include prescribing
medication, physiotherapy, supportive psychotherapy, family
support, use of day care, referral to Old Age Psychiatry or Aged care
Services, social services and hospital admission.

Prescribing for the elderly

Certain principles should be borne in mind when prescribing for the

elderly.

1. Avoid polypharmacy - though they have multiple diseases, the

doctor should use the minimum number of drugs. Quite often,
rather than drugs, the patient may need only counselling and
ventilation of feelings to overcome loneliness and depression.

2. Look out for self medication with Over The Counter (OTC)
medicines.

3. Use drugs in small doses as excretion may be diminished due to

poor renal function. Eg. digoxin could accumulate and lead to
unpleasant and dangerous side effects.

4. The elderly are also more prone to adverse reactions eg.

constipation with tranquilisers, postural hypotension and falls
with diuretics and antihypertensives, GIT bleeding with
NSAID’s.

5. The elderly often need supervision of drug therapy, as they may

forget to take the drugs. Conversely they may take an overdose
either deliberately or due to forgetfulness.

Guidelines are :-

* Consider whether a drug is indicated at all

* Use drugs that are known or have been used before in the
elderly
* Use smaller doses
* Review regularly
* Drugs which need to be given once a day or twice a day are
better than ones that need to be given more often
* Use a minimum number of drugs
* Use liquid preparations if the patient is unable to swallow tablets
* Ensure that the medication is given under supervision of a
relative or care giver after educating the carer how the
medicines should be given.

Caring for the elderly

In Western countries, the care of the elderly is well organized having

special geriatric hospitals or geriatric wards in general hospitals for
acute illnesses etc. Those who are not ill but nevertheless need care,
are looked after in nursing homes and homes for the aged. Homes for
the aged also exist in Sri Lanka and other South Asian countries, for
those who do not have family members to care for them. These
homes are run by charitable and religious organizations and by
Helpage, an organization run by the Social Services Department.

In developed countries where a care giver is looking after the patient

at home, there is a team of health personnel such as the family
doctor, nurses, physiotherapists, speech therapists, social workers
etc. to share in the care of the elderly patient in the home. In Sri
Lanka, no such organization exists but for families who have the
ability to pay, home nursing services and physiotherapy could be
arranged where such services are available. The family doctor has
an important role to play and could share in the care of the elderly by
doing home visits when necessary.

In Sri Lanka and countries in South Asia, the elderly are often cared
for by the relatives. The extended family system still exists and
ageing parents are cared for by their children. Children who are
caring for the elderly are usually middle aged and may be facing
other stresses which are common to that particular stage of the
family life cycle. The doctor’s role should therefore involve
understanding of the care givers’ problems as well and counselling
them appropriately.

Attention to the Caregiver (The other patient!)

It is the doctor’s duty to pay a fair amount of attention to the

caregiver who is usually a very close relative or may even be a
friend, neighbour or paid nurse.

Caregivers suffer from stress of the caring role and may end up
suffering from the caregiver syndrome.

Definitions of the Caregiver Syndrome:

A debilitating condition brought on by unrelieved, constant

caring for a person with a chronic illness or dementia. (Latham
PH, Posner J. 2006).

A syndrome found in caregivers involving pathological, morbid

changes in physiological and psychological function. This syndrome
can be the result of acute or chronic stress, directly as a result of
caregiving activities. (Guia DM. 2003.)

Caregiver Stress

Caregiving can cause ill health in the caregiver. Research has

shown that elderly caregivers are at a 63 percent higher risk of
mortality than non caregivers of the same age group.
The physical symptoms of caregiver stress are a result of prolonged
and elevated levels of stress hormones circulating in the body. It
could lead to high blood pressure, diabetes and a compromised
immune system. Some researchers have likened exhausted
caregivers' stress hormone levels to those suffering from post
traumatic stress disorder.

Physical symptoms of caregiver stress

 Fatigue
  Insomnia
 Stomach complaints
 An increased risk of cardiovascular disease
 An increased susceptibility to infection
 Humoral and cellular immune dysfunction
 Adrenal exhaustion
 Altered catecholamine, steroid and hormone levels
 Disruptions in the hypothalamic-pituitary-adrenal axis

Emotional symptoms of caregiver stress

 Grief
 Anxiety
 Resentment
 Anger
 Fear
 Helplessness
 Despair
 Depression

Many caregivers even though exhausted with their role and feel ill,
do not seek help for a number of reasons. The main reason is that
they are so involved in their caregiving role that they neglect their
own health. Another is, that they may not even realize they are
suffering from caregiver stress. In addition their emotional
symptoms may be aggravated when they see a decline in the health
of their loved ones.

Therefore it is important for doctors to recognize caregiver stress

and help caregivers through counselling and suggest caring to be
taken over by someone else until the caregiver recovers from the
stress and exhaustion. Understanding of the situation and empathy
by the family doctor could ease the burden and help the caregiver to
make adjustments to ensure recovery from stress arising from the
care giving role.
 Chapter 15

HOUSE CALLS AND HOME CARE

Twenty to thirty years ago, house calls were an important part of the
family physicians work. The family physician used to make house
calls more often than now and even attend to deliveries at home. In
modem times, with improvements in transport facilities and better
health care, home visits have become rare and home deliveries by
doctors almost nonexistent as most mothers deliver in hospital.

In the USA and Canada, family physicians do at least one house call
per day. A survey in the USA in 1991 showed that 50% of family
physicians and internal medicine physicians carry out home visits. In
the UK and Europe doctors may do several home visits on a single
day. In Sri Lanka too, family physicians undertake home visits when
the need arises to care for a patient in the home. The one day general
morbidity survey in 1996, in which 40 GPs participated, showed that
only one home visit had been carried out on the day of the survey.

Home care is very different to care in the office or hospital and has
certain unique characteristics. Home care shifts the focus from the
disease oriented model to a style of care that acknowledges the
patient as an individual. Moreover, the physician has to adapt office
based practice techniques to provide care in the context of the
patient’s home environment. In this new setting the doctor has to
surrender his or her control over the care of the patient, as the doctor
is now a guest in the home of the patient and family. The doctor in
this situation is forced to tolerate and respect different ethnic,
religious and cultural practices and has to be flexible in adapting to
the limitations imposed by the home environment on standards of
care. The brighter side to this is the enriching experience the doctor
gets, by seeing the physical and psychosocial milieu of the patient’s
real world which the doctor would never have known, had he seen
the patient only in the office or surgery. Most importantly, a house
call enhances and strengthens the bond with the family and the
doctor -patient- family relationship. Therefore the benefits of a home
visits when indicated, far outweighs some of the disadvantages
which will be discussed in more detail later.

Indications for home visits

Home visits by the doctor are specially necessary in the care of the
elderly, but may be necessary in any situation where the patient
cannot be brought to the doctor.
* Care of the elderly, disabled and bedridden patients. The doctor
may undertake routine visits on a monthly or weekly basis. The
doctor will also visit the home in case of an acute illness or
problem such as a fever, a fall, respiratory illness or prolapsed
haemorrhoids.

* Care of the terminally ill or care of the dying patient at home,

where active medical treatment has been given up and only
palliative care is indicated. In such instances, the doctor would
have to pay attention to the relief of pain by giving analgesics in
adequate doses. Intravenous fluids or a nasogastric tube may be
necessary for feeding and catheters may have to be changed. The
doctor can also help by just being available and by offering
psychological support to the patient and family.

* Acute illness or injury where the patient cannot be brought to the

doctor’s surgery. Eg. a fall or a faint or a chest pain or severe
backache where the patient is unable to get out of bed due to the
severe pain. In all these instances, the doctor may have to make
an initial assessment and decide whether the patient should be
admitted to hospital and if so how the patient should be
transported to the hospital. On the other hand the doctor may
decide to manage the patient at home, specially if the patient is
elderly, depending on the amount of family support and other
facilities available in the home.
* Patients discharged from the hospital following major surgery.
There may be a need for medical care to be continued at home,
such as the dressing of the surgical wound or the changing of
catheters.
* Mother and new born baby during the postpartum period. The
mother may have an infected episiotomy wound or a tear or
prolapsed haemorrhoids after partus and may find it painful to
walk. The doctor will also have the opportunity of seeing the
newborn baby, the state of the umbilical cord, give advice
regarding breast feeding etc. The doctor visiting the home to
see a newborn baby will also prevent the baby from being
exposed to infections from other children in the waiting room
of the doctor’s surgery.
* Patient having an infectious disease such as chicken pox. If
such patients need to be seen by a doctor, the doctor should
visit the patient at home. This would prevent the patient
coming to the doctor’s office and infecting other patients, such
as pregnant mothers and the elderly in whom such infections
could be dangerous.

* Mentally ill patient who is refusing to go for treatment or who

is aggressive and needs sedation. Even an aggressive or
uncooperative mentally ill patient is more likely to yield to
gentle persuasion from his or her own family doctor, whom he
or she has leamt to trust over the years.

* Mentally retarded child who is liable to fits and is being

looked after at home by the family. The family may prefer the
doctor to attend to such a patient at home.

The above are some of the common indications for home visits but
obviously there are many other indications. It is up to each doctor to
use his/her judgment to decide whether a particular patient needs to
be seen at home.

The process of making a house call

House calls are usually done on requests made by the care givers and
relatives and the doctor will oblige only if he or she considers it
necessary to visit the home to see the patient. Home visits may also
be initiated by the doctor, if the doctor feels that a patient would
benefit from a house call. This is done in situations where a patient is
not complying with treatment, when a patient is depressed or when
there are psychosocial problems such as child abuse or elder abuse.

Family physicians who carry out regular home visits, may either set
aside a time of the day such as the afternoon or a particular day of
the week for routine home visits. Prior to the visit the doctor should
check the patient’s medical record, discuss the objective of the visit
with the family /care givers and arrange a mutually agreeable time
for the visit. Where acute problems are concerned, the visit has to be
done as soon as possible and will have to be fitted into the doctors
existing schedule of a particular day.

During the visit, following initial greeting and social interchange, the
doctor will concentrate first on the medical aspects of the visit such
as checking of vital signs, doing a physical examination, taking
blood, administering medications etc. While attending to the patient,
the doctor should simultaneously assess the physical and social
environment of the patient by observing the surroundings and the
social interactions taking place between members of the family and
care givers. Reassurance, giving psychological support to the care
givers and paying attention to the care giver’s health should not be
forgotten as they are important aspects of home care.

After the visit, the doctor should make arrangements for a follow up
visit if necessary and make notes in the medical record of the patient
if it had been brought in the doctor’s bag. The doctor could make out
a bill for later payment or accept payment at the time of the visit.
Doctors however do not charge all the time and many visits may be
done free of charge, specially where there is a real need to see the
patient at home. The charge from a particular patient may also
depend on the family’s income and ability to pay.

Advantages of Home Visits to the doctor

* The doctor gets the opportunity of seeing the patient in his or her
own home environment. This will give the doctor a lot of
information about the patient and the family that may not have
surfaced during an office visit. The doctor would notice the
cleanliness of the home, the socioeconomic conditions, layout of
the house-whether it is suitable for an elderly patient to move
about or whether the disabled patient has to climb steps to go to
the bathroom The doctor would also notice the patient who is
always kept in bed and not made to sit out of bed or the bottle of
over the counter medications (OTC) lying on the table. The
 doctor may detect indifference by the relatives towards the
elderly patient and indeed any signs of neglect or abuse.
* The doctor would notice the medicines and dangerous objects
kept within the reach of children or may see children playing
around an unprotected well. The good family doctor would take
note of all these things and give appropriate advice and health
education to the patient and the family.
* Doctor gets to know the family better and would meet members
of the family he or she had not seen before, notice how they
interact with each other, how caring and kind they are to the
elderly patient etc. The doctor could use this opportunity to
involve others such as grandchildren in caring for the elderly
patient. The patient and the family are also better able to express
their feelings, and talk about their problems more freely during
home visits than in the doctor’s surgery. Therefore, the doctor
gets a better insight into the family problems. The home is a good
place to do family counselling as well.
* The home visit by the doctor helps to strengthen the doctor-
patient relationship and the bond that the doctor has with the
patient and the family.

Disadvantages to the doctor

* Doctor has to spend more time on a home visit, as each home

visit would take at least half to one hour.
* Doctor has to examine the patient with minimum equipment and
facilities. The home may be poorly lit and the patient may be
lying on a mat or on a low bed. The doctor may also not be able
to take all the equipment necessary for a proper examination of
the patient.
* There may not be enough privacy to examine the patient as
anxious relatives and others such as neighbours may be around.
* Sometimes the doctor may be exploited by patients who call the
doctor unnecessarily. A doctor may also be called by patients
other than those in his or her care, because their own doctor had
refused to visit the home.
* Getting through heavy traffic, difficulties in parking near the
patient’s home and other inconveniences are faced by doctors
when they do home visits.
* Doing home visits may interfere to some extent with the doctor’s
own personal and family life due to the time taken up in doing a
home visit.

Thus family doctors have to work within all these constraints, but
they should not avoid doing home visits which are an integral
component of good quality patient care.

Advantages to the patient

* The patient and the family will have the satisfaction and
convenience of having their own family doctor visiting the home
and giving them personalised attention.
* Problems of transporting the patient and waiting in a queue in the
doctor’s surgery too are avoided.

Disadvantages to the patient

* Patient’s family may want to tidy up the house for the doctor’s
visit. They may feel embarrassed about the doctor seeing their
living conditions.

Patient may have to pay more for a home visit than for an office
visit.

The Doctor’s bag

What is taken in the doctor’s bag will also depend on the reason for
the home visit. What should a doctor take in the bag when he or she
goes on a home visit?
In general the doctor’s bag will have the following items of
equipment:-
* Stethoscope
* BP apparatus
* Torch
* Ophthalmoscope and auriscope
* Knee hammer
* Tongue depressor, thermometer
* Peak flow meter

* Cotton wool, gauze, spirits, bandages, plaster, suture material,

needles and gloves
* Disposable syringes and needles, alcohol swabs
* Bottles for collection of specimens eg. Patient who is thought to
be in a hypoglycaemic coma may need to have blood drawn for
blood sugar estimation before being given IV dextrose

* Urine dipsticks, glucometer with lancet and strips

* Nasogastric tubes, Foley’s catheters
* Normal saline, 5% dextrose, 50% dextrose
* Emergency drugs in injection form such as morphine, adrenaline,
frusemide, aminophylline, hydrocortisone, prochlorperazine,
promethazine, chlorpheniramine, diclofenac sodium

* Prescription pads, letterheads, pen, rubber stamp of doctor

* List of phone numbers of hospitals, pharmacies and ambulances

 Chapter 16

BREAKING BAD NEWS, PALLIATIVE

CARE, THE DYING PATIENT AND
BEREAVEMENT

Breaking bad news

Breaking bad news is a subject that has been neglected in the past in
medical education but has recently gained importance in
communication skills training programmes for medical students and
postgraduate doctors.

Breaking bad news may be defined as “any information which

adversely and seriously affects an individual’s view of his or her
future”

Breaking bad news most often refers to telling a patient and the
family or both, that the patient has been diagnosed as suffering from
a terminal illness such as cancer, leukaemia or AIDS.
However, breaking bad news could also include many other
situations such as the following:-
* When the parents of an infant have to be told that their baby
has a congenital heart disease which has a bad prognosis.
* Informing the parents after the delivery that their baby was
stillborn .
* Informing relatives that their family member succumbed to
the injuries following an accident in spite of the doctors
doing everything possible.
Whether the news is considered to be bad or not is also influenced by
a number of factors such as the context in which it occurs, the way in
which it is perceived and interpreted by the patient and the family
and the manner in which they react to it. For example, a person may
feel that being told he is suffering from TB, is bad news because of
the social stigma, although he knows that the disease can be cured.
This may also occur when a family gets to know that one of its
members is suffering from a serious mental illness such as
Schizophrenia. So bad news is a relative concept and the news may
be considered to be bad by the patient and the family, if they feel that
it is likely to adversely affect their future in some way.

In the remaining part of this chapter, breaking bad news will deal
with patients who have been diagnosed as having cancer although
the same principles may be applied to any other situation referred to
above.
Most often breaking bad news refers to, telling the patient and or the
family, the diagnosis of a terminal illness such as cancer. It is one of
the most difficult tasks that doctors have to do in their professional
lives.
What is difficult about giving bad news ?

Doctors may find it difficult to give bad news because they may
 feel responsible and fear being blamed.
 not know how to give the news.
 worry that it will change the existing doctor-patient relationship.
 fear the patient’s reaction on hearing bad news.
 uncertainty of what may happen.
 worry about not having answers to the questions that may be
asked.
 worry about their own feelings and reaction to it.
 fear of doing it wrong or of giving the wrong information.

When a doctor is faced with the task of telling the patient and the
family bad news, such as the diagnosis of cancer, the doctor has to
decide -
* Whom to tell
* When to tell
* What to tell
* How to tell

Doctors who have undergone training in breaking bad news will find
it easier to decide as to what the best approach would be. If the
doctor is in a dilemma as to what should be done, it would be
advisable to discuss how to do it with another doctor.

In deciding whom to tell, and when, the doctor should know the
patient’s personality, patient’s previous reactions to illness and the
family resources and support available to the patient and so on. The
doctor will then have an idea, whether the patient would want to
know the truth and has the resources and the ability to cope with it.

There are patients who want to hear the truth and such patients have
the right to be told the truth. On the other hand there are patients who
do not want to know the truth, and this is common in Asian cultures
where people tend to shy away from unpleasant news. Such patients
have the right not to have the truth forced on them before they are
ready for it. In Western countries, the doctor may be sued for not
telling the whole truth to the patient. Sometimes it is the members of
the family who try to keep the truth from the patient and ask the
doctor not to tell the patient as they are afraid of the effect it may
have on the patient. This places the doctor in a very difficult situation
as it means having to lie to the patient. However, the patient soon
finds out the truth when he or she is sent for radiotherapy to the
cancer hospital. If the doctor had lied to the patient about the illness,
the patient may lose confidence in the doctor. A good guide may be
to wait for the patient to ask the doctor directly. If the patient asks
the doctor directly, the doctor should not lie but break the news as
gently as possible and in stages, so that the news gets stretched
through one or more consultations. This will allow the patient
sufficient time to get used to the idea that he or she has a terminal
illness.

With regard to what to tell and how to tell the patient, there are two
options. These are -
1. Full disclosure (To give the patient the full information)
2. Individualized disclosure (To use a flexible approach)
In Asian cultures, individualized disclosure would be the best option
to use.

This means first finding out what the patient already knows about the
illness and whether the patient is prepared to hear the truth. For
example the doctor could proceed as follows:-

To get an idea whether the patient already knows or wants to know

the truth, the doctor could ask the patient “What ideas do you have
about your illness or do you know what your illness is?” The patient
who wants to know may say “I suppose it is a cancer” while the
patient who does not want to know may say “I hope it is nothing
serious”.

In this way the doctor could get some idea as to what the patient
already knows. If the doctor feels that the patient is not ready to hear
the news, it could be postponed until a later consultation. However,
the relatives will have to be told, as treatment cannot be delayed.
If the doctor feels the patient is ready to know the truth, the truth
could be stretched over a few consultations as follows:-

Doctor : I think this could be a tumour and we will have to do some

tests
to find out.
Patient: Is it something serious?
Doctor : We can’t be sure until the reports come.

Once the test results are available,

Doctor : the report is not very good but you are lucky that it has been
detected early. We should be able to cure it with the modem
treatment available.

In this way the patient could be told the bad news gently and with a
sense of hope and reassurance that everything possible will be done
to treat the condition.

Various protocols have been developed for breaking of bad news.

The one described by VandeKieft in 2001 follows the simple
mnemonic ABCDE and is shown below.
A - Advance preparation - arrange adequate time and privacy,
confirm medical facts, review relevant clinical findings and
emotionally prepare for the encounter.
B - Build a therapeutic relationship - identify patient preferences
regarding disclosure of bad news.
C - Communicate well - determine the patient’s knowledge and
understanding of the situation, proceed at the patient’s pace,
avoid medical jargon, allow for silence and tears and answer
questions.
D - Deal with patient and family reactions - assess and respond to
emotional reactions and empathize with the patient.
E - Encourage / validate emotions - offer realistic hopes based on the
patient’s goals and deal with your own needs.

While the above protocol could be used for breaking of bad news in
any situation, more specific protocols such as the SPIKES protocol
are available in journals of Oncology for breaking bad news of the
diagnosis of cancer.

A patient who hears bad news may go through the following stages.
* Incredulity - This is the stage of disbelief. The patient will think
 that the doctor has made a mistake and may seek another opinion.
*Anger - When the patient realises that the doctor has not made a
mistake and that it is really true, the patient may become angry,
may find fault with herself, with her family or with the doctor.
* Acceptance is where the patient will accept the inevitable.
* Despair is when the patient gives up hope and goes into a state of
depression.
All patients who are told bad news, do not go through all these stages
and when they do, not necessarily in the same order. Sometimes the
order may be reversed or they may be in more than one stage at the
same time. It is important for the doctor to be aware of these stages
and be prepared to respond appropriately to the patient’s reactions.

Those who are able to accept bad news may be people who find
solace in their religion. The patient who goes into a state of
depression would need empathic understanding and counselling by
the doctor.

When sharing bad news, the doctor should maintain eye contact and
communicate effectively with the patient. Touching the patient, if
only to feel the pulse or patting the patient on the shoulder, - will go
a long way in reassuring the patient that the doctor will be available
to offer supportive care throughout the illness. It is also important for
the doctor to sound positive about modern therapies available to
bring about a cure, which will give the patient a sense of hope that
something could be done for the treatment of the illness.

The doctor would also have to talk to the patient’s relatives.

Sometimes the relatives may find it harder to receive the news of a
fatal disease than the patient. Thus, the family members may need as
much support from the doctor, as the patient.

Once the patient starts therapy, the patient may get depressed and
anxious due to the side effects of therapy and the doctor will have to
counsel and support the patient to cope with the illness. The family
doctor should also involve the family members in the care of the
patient, while continuing to offer support to the patient and the
family.
What is known about how patients and relatives want bad
news to be conveyed?

Research in western countries has shown that when patients who

have had cancer were asked how they expect bad news to be given,
they have stated that they would like the doctor to be truthful, caring
and compassionate and to give direct non technical explanations.
They valued time given to talk, express their feelings and ask
questions. The ability of a doctor to create a personal relationship,
has been found to influence the capacity of a patient to cope with bad
news.

Physicians who had been asked to recall a time when they had
delivered bad news reported that they had followed published
recommendations, had found it stressful and that the stress had lasted
beyond the bad news encounter with the patient.

Research in Sri Lanka on the perceptions of patients and doctors on

the conveying of bad news is scarce. A preliminary study by the
author where semi-structured interviews were carried out with 8
patients taking treatment in the wards of the cancer hospital revealed
the following:-
* In most instances the bad news had first been conveyed to a
relative.
* When the patient had been told directly, it had been either
traumatic or had caused minimal harm.
* Most were glad that they had finally got to know about the
cancer, as they said that it had allowed them to plan for their
future and that of their children
* The patients / relatives feelings on hearing the bad news were
crying depression and anxiety.
* Patients were satisfied with the kindness shown by the doctors.
* Most did not ask questions from the doctors.
* They would have preferred if doctors had told them about the
 side effects of drugs.

A few doctors who were interviewed in Sri Lanka stated that they
had been worried as to how to give the news and had felt depressed
afterwards.
In summary, when conveying bad news, physicians must have
appropriate attitudes and deliver the news in a caring and sensitive
manner, so that the patients’ morale can be maintained and the
patients will be able to come to terms with the illness with realistic
expectations and hope.
To help physicians deal with their own discomfort, training in the
delivery of bad news should include guidance on cognitive and
behavioural coping strategies.
A life threatening or incurable illness

There are five stages in the care of an incurable illness

1. Diagnosis of an incurable illness - Care involves breaking bad
news as described earlier and being positive with regard to
treatment and hope of a cure.
2. Transition from curative treatment to palliative care.
3. Stage of deterioration - the patient begins to go downhill and
becomes dependent on others for regular nursing and medical
care.
4. Terminal stage - the patient is completely dependent on life
support and is unable to respond to those around. All decisions
regarding the patient’s welfare has to be made by the doctors and
members of the family.

5. Death of the patient - bereavement care.

Following the diagnosis of an illness such as cancer or AIDS, the

doctor will break the bad news to the patient and family. Doctors will
then embark on treatment that is aimed at a cure. If and when the
doctors find that a complete cure is not possible, there will be a
transition in the care from curative to palliative. This comes with the
realization that the patient’s illness is progressive and life-
threatening, and that death is likely in the not too distant future.
There is no sharp demarcation between curative care and palliative
care. Palliative care may start during the stage of deterioration of the
patient’s condition but may be earlier or later. The patient and family
too have to accept that palliation is the goal of management.
Depending on the type of patient and the culture, the relatives alone
and not the patient may be involved in such a decision. In Asian
cultures, the decision may be left entirely in the doctor’s hands.
However, it is important for the doctor to know whether the patient
wants to be involved and if so, to involve the patient in making
decisions about future management.

Some patients may decide to accept palliation much earlier in the

disease than others, when for example they reject a second course of
chemotherapy. In Western societies, patients who have an incurable
illness as well as elderly patients, sometimes make a ‘living will’ or
an ‘advanced care directive’ in which they state, that when the end is
near they do not wish to have their lives prolonged by artificial
means such as passing of nasogastric tubes, external cardiac
massage, defibrillation or ventilation. In Asian cultures, although
people do make such requests verbally, it is rarely put in writing. The
reverse could also happen, where the patient and family refuse to
accept that death is inevitable and want the doctors to try all possible
modes of therapy.

A patient may also remain undecided, where the patient wavers

between the benefits of prolonging the illness in order to achieve
some personal event in life, weighed against the discomfort from
invasive procedures and adverse reactions to drugs.

What is palliative care ?

Palliative care is the active total care of patients whose disease is not
responsive to curative treatment. The goal of palliative care is
achievement of the best quality of life for patients and their families.

Cancer pain relief and palliative care.

WHO Geneva 1990

In most clinical situations the principal aim is to cure the disease and
relieve symptoms. In palliative care, the principal intent is to
ameliorate symptoms and maximise the quality of the patient’s
remaining life.

Investigative procedures should be kept to a minimum. The

symptomatic benefit of therapeutic procedures such as surgery and
radiotherapy should clearly outweigh the disadvantages.

Palliative care cannot be delivered by doctors alone. It requires a

team of providers such as family members, doctors, nurses,
counsellors and the clergy who should cooperate with each other in
providing care. Such resources may not be available in all health care
settings.

Who should receive palliative care?

Patients with advanced cancer and HIV/AIDS are the most common
recipients of palliative care. However, patients with other
progressive diseases such as end stage organ failure, progressive
neurological disorders, coma due to a stroke etc would also benefit
from palliative care. Patients can be of any age.

The dying patient

Dying is a normal event and is the final stage of the human life cycle
although some may die prematurely due to disease. Many years ago,
most people died at home. Patients accepted death with dignity,
knew that death was imminent and had time to put their affairs in
order such as writing a will, making up with estranged relatives and
so on. But in modem times, patients who are in the terminal stage of
the illness are taken and isolated in a hospital and separated from
their loved ones. Doctors focus their attention primarily on the
disease which has reached a terminal stage. The person as a whole is
neglected at a time, when the patient most needs care directed at his
or her emotional and social well being. This is because most doctors
have been trained to cure diseases and doctors find it uncomfortable
when confronted with death. However, it is important for doctors to
be aware that they can do a lot to alleviate suffering and offer
psychological support and comfort to the patient and the family.
When the patient dies, the doctor can comfort the bereaved. Thus,
communicating with a dying patient and the family though an
unpleasant and difficult task is a doctor’s duty. Knowing how to do it
will make a doctor less anxious when having to deal with such
difficult situations.

Care in the stage of deterioration and the terminal stage -

There are four main components of palliative or terminal care which
may be carried out in the hospital or in the patients home. Whenever
possible, the family should be encouraged to care for dying patients
at home with support from the family physician.
Components of Care
1. Psychological care and supportive care
2. Physical care and medical treatment
3. Social care and spiritual care
4. Supportive care of the family

1. Psychological care or supportive care - is the management of the

psychological needs of the dying patient and the close relatives. This
could be offered by the doctor in the hospital or by the family doctor
if the dying patient is at home.

To be able to provide psychological support to the dying patient, the

doctor should know the patient’s personality and the manner in
which the patient views death. The family physician is ideally placed
to provide this kind of care, because the doctor has known the patient
over a long period of time and is regarded as a family friend.
Because of the close relationship the family doctor has with the
patient and family, he or she may find it difficult to accept that the
patient is dying. To provide support to the patient, the doctor should
remain objective and detached and at the same time offer
compassionate care to the patient within an existing doctor-patient
relationship.

It is important to remember that the human interaction of presence,

touch, and careful listening are significant aspects in the care of the
dying patient. Being at the patient’s bedside, communicating
effectively, showing concern, touching the patient when appropriate
and listening to the patient would be comforting and reassuring for
the patient. The doctor should listen to the patient’s fears,
frustrations, hopes and needs. The patient may fear pain, dislike
being dependent on others, fear becoming incontinent or fear being
separated from the family. The patient would be able to overcome his
or her fears by discussing them with the doctor who could reassure
the patient by offering symptomatic relief and psychological support.
Patients who have been allowed to discuss their feelings have been
found to experience less pain and less anxiety, accept their situation
more readily and need less anxiolytic drugs in the terminal stage of
their illness than those who had not been given this opportunity.
On the other hand, some patients may not want to talk about their
illness at all and their wish too should be respected.
While talking to the dying patient, it is also important to maintain a
glimmer of hope so that the patient may live the remaining part of
his or her life to the fullest that the condition will allow, without
going into a state of depression.
2. Physical care and medical treatment for relief of pain and other
symptoms - In a patient whose death appears to be inevitable due to
an incurable disease which has entered its terminal stage, the most
important aspect of care is relief from suffering.
A doctor’s duty is to act in the best interests of the patient. Therefore
in a patient whose death appears to be inevitable, unnecessary
investigations and medical treatment which will not make a
difference to the prognosis, but only aggravate the patients suffering
should be avoided. As it requires good clinical judgment to decide
when the illness is at a terminal stage and death is deemed inevitable,
the transition from curative to palliative intent should be made by the
most senior and experienced doctor involved in the care of the
patient. Whatever decisions regarding the patient’s treatment at this
stage should be done, after discussion with the patient’s relatives.

The most important part of physical care in a patient who is about to

die, is to keep him or her as comfortable as possible until death.
Therefore, relief of pain becomes an important aspect of physical
care.

Relief of pain is specially indicated in a patient dying of cancer. Up

to 50% of patients with advanced cancer experience pain and as the
disease progresses, the pain becomes severe and persistent. The aim
of pain relief in such patients should be to keep them pain free
throughout the 24 hours, during rest, during movement and in sleep.
Analgesics should therefore be given in adequate dosage, at regular
intervals of time throughout the 24 hours. Doctors should not
withhold medication which is known to be addictive, because the
problem of addiction is not relevant in a patient who is about to die.
It is more important to let the person Jive the last few days of his or
her life with as little pain as possible. Simple analgesics should be
given first followed by opiates. Oral medication should be prescribed
whenever possible and parenteral therapy used only when oral
treatment is no longer effective. Opiates themselves could cause
uncomfortable side effects such as constipation and this should be
borne in mind.

Symptom relief is also necessary for symptoms such as nausea and

vomiting, cough, dyspnoea, constipation, diarrhoea, incontinence etc.
These symptoms should be relieved by appropriate treatment.
Anxious and depressed patients may need anxiolytic drugs. By
relieving anxiety with anxiolytic drugs, the dose of analgesics
required for pain relief may be reduced.

Diet is another aspect of physical care. The doctor should advise the
relatives to give adequate food and liquid to the patient in a form that
could be easily swallowed and digested by the patient, who is in a
weak state. Vitamins too may be prescribed.

Aids, appliances and equipment such as bedside commodes,

wheelchairs and special mattresses too may be needed.

3. Social care - A dying patient may find solace in religion when near
death. The doctor should encourage the relatives to pay attention to
religious and cultural practices to help the dying patient. The dying
patient may also express a wish to write his or her last will and
appropriate arrangements should be made.

4. Care for the family - The doctor should provide emotional support
to the family members by offering counselling and supportive
psychotherapy, to prepare them for the impending death of a loved
one. Finally after the patient has died, the family doctor has to care
for the bereaved.

Death of the patient

Death if it happens at home has to be certified by the family doctor.

Sometimes the doctor is called when the patient is breathing his last
few breaths. Not only is this stage an emotional one for the relatives,
it is also a traumatic experience for the doctor. While attending to
minimally invasive interventions such as giving of oxygen to help
the patient’s breathing easier, the doctor could advice the relatives to
attend to spiritual needs of the patient eg. chanting of pirith* or
prayers depending on the patient’s religious faith. Once the patient
dies, the doctor has the unpleasant task of informing the relatives that
the patient has died. Although death may have been expected in a
terminally ill patient, nevertheless it is a very emotional and sad time
for the loved ones. The family doctor is the one who could offer
psychological support at this time. The doctor also has to attend to
administrative matters such as writing the cause of death to the
Registrar of Deaths who will issue the death certificate.
_________________________________________
*Buddhist custom to invoke blessings

Bereavement care

Ideally preparation of the family for bereavement should begin

during the period of palliative care and doctors should counsel the
relatives about the possibility of death of the patient. Whether the
patient dies in the hospital or in the home, it is the family physician
who takes the responsibility to care for the bereaved members of the
patient’s family. The bereaved family will experience a sense of loss
following a death in the family and will need care and support from
their family physician.

Grief reaction is a state of distress, caused by deep sorrow resulting

from the death of a loved one.

Grief is a normal reaction and may involve three stages.

Stage I - stage of shock or disbelief. The realisation of the loss

begins with a sense of numbness and lasts for a few days where the
loss has not been felt yet. Somatic symptoms may occur such as
shortness of breath, loss of appetite, choking sensation, tightness in
the throat, empty feeling in the stomach and so on.

Insomnia is common and night time sedation may be required. Too

much day time sedation should be avoided, as it may prevent the
grief from running its natural course. The physician should not rush
the grieving process but allow it to proceed at its normal pace. Those
who express grief openly are less likely to remain disturbed at a later
period, than those who suppress their grief in the early stages. It is
usually the family physician who is called to the home to care for the
grieving relatives during a funeral and he or she should be available
to support the family throughout the grieving process.

Stage II-The period of pining. The loss of the person is felt acutely
and the bereaved person may be preoccupied with memories of the
diseased. Perceptual disturbances with fleeting illusions and
hallucinations about the deceased though rare have been reported to
occur. Social contact with others is avoided, because sympathy may
aggravate the sadness. This stage lasts up to two months. The
bereaved may feel guilty and sometimes blame themselves for the
death or of having been unkind to the person before death. They may
present to the doctor with a variety of symptoms such as tiredness,
backache, anorexia, headache and other anxiety related symptoms.

Stage III - Period of depression. This period is marked by reactive

depression and apathy. Trying to get back to normal activities is
difficult. This may last as long as a year. The total period of grief
should not last more than two years. Recovery requires acceptance
that the loved one is lost but that life must somehow go on.
Developing a close relationship with other relatives and friends may
help in recovery.
After the period of grief is over, some people experience anxiety
related symptoms and unhappiness on anniversaries of the deceased
person’s death and on birthdays etc. This is called the Anniversary
Reaction.

Throughout the period of grief and during anniversary reactions, the

family physician should be able to counsel the patient and offer
supportive psychotherapy.

Complicated grief
Grief is said to be complicated when the following features are
present;-

* Extremely intense emotional reactions and inability to cope.

* Prolongation of distress over one to two years or more without
evidence of grief getting less.
* A number of physical and emotional problems; impairment of
sleep, social functioning and work capacity; social withdrawal.

Depression and anxiety may develop in 20% of grief reactions and

need specific treatment.

The degree and duration of grief depends on many factors such as –

* Relationship to the deceased. Spouses feel the loss more than

children. Parents feel the loss of a child more than children do of
parents.
* Strength of the bond. The stronger the bond, the more likely
he/she will be missed.
* Dependence on the deceased. Where there has been emotional or
financial dependence on the deceased or both, the loss is felt
deeply as the bereaved person becomes helpless.
* Duration of the terminal illness. A sudden death is felt more
deeply than when death has been expected for some time. When
the deceased has been in pain and distress for a long time, death
 may bring a sense of relief that there will be no more suffering.
* Emotional make up of the remaining family member. A highly
emotional person may feel a sense of anger or self reproach or
develop reactive depression more than others, who are not so
emotional.
* Anticipatory grief. Where counselling of relatives has been done
in anticipation of death, the grief reaction is less.
* Age of the deceased. The loss is felt less when the age of the
deceased is very young or very old.
 Age of the bereaved. Children appear to accept death in a family
more readily than adults. Children who have lost a parent before
adolescence are more likely to have emotional disorders in later
life.

The family physician who is aware that a death has occurred in a

family, should be on the look out for physical and emotional
problems in the bereaved family. The doctor should counsel the
bereaved to help them overcome their grief and accept reality.
Religious and cultural practices too help the relatives in overcoming
their grief.
Studies have shown that recently bereaved people are more prone to
ill health and consult doctors more often than others. Emotional
disorders may present in the guise of physical complaints. Some
people suffer the same symptoms as the deceased person had.
Mortality rate has also been found to be higher in the remaining
spouse following the death of a spouse, when compared to persons of
the same age and sex in the general population.

In families where a child has died, psychological problems such as

marital problems and alcoholism could occur in the parents, while
the remaining children may develop behaviour problems. Since
many bereaved persons turn to their family doctor for support during
the time following a death in the family, it is the family physicians
responsibility to be available during this period to provide
counselling and supportive psychotherapy to the family.
 Chapter 17

MEDICAL RECORDS
IN FAMILY PRACTICE

The medical record is an essential tool for the family physician. Well
maintained records are very necessary for good quality patient care
in family practice which involves the continuing care of patients over
a long period of time.

The information in a medical record should be organized in a

systematic and logical manner and should reflect the patient’s state
of health accurately. The medical record should contain all the
relevant information regarding the patient’s present and past medical
problems, family history and social circumstances. The medical
record should contain information that would make the family
physician aware of potential problems that may surface in the future.

Purpose of a medical record

1. Useful in the day to day management of acute illness.
2. Useful in the long term management of chronic illness.
3. Helps to communicate facts about the patient to a new doctor
who may be acting for the regular family physician.
4. Useful in preventive care and identification of risk factors eg.
decline in the rate of growth of a child .-as indicated in the child
health development record or a family history of ischaemic
heart disease in a patient with hypertension.
5. Useful for research eg. retrospective surveys.
6. Useful for clinical audit to evaluate the quality of medical care.
7. Useful for medico-legal purposes eg. if a doctor is accused of
medical negligence, the fact that the doctor has written the
details of the consultation in the patient’s medical record will
earn credibility in the eyes of the law. Also, if the doctor is
called upon to give evidence in court with regard to a patient
who had been treated for an injury following an assault, the
details of the injury would be available in the medical record.

Characteristics of a good medical record

* The indexing and filing system should be organised in a way
that makes retrieval of the medical record quick and simple.
* The size of the medical record should be such that it could be
easily stored.
* The contents should be organised and structured so that
recording is simple and retrieval of information is quick and
easy.
* Should contain all the relevant information about the patient’s
medical and health problems such as diagnoses, results of
 investigations, treatment, referral, hospitalizations etc.
* Entries should be clearly written, accurate and legible. A
doctor who cannot read his own notes when called upon to do
so in a court of law, will not make a good impression.
* Abbreviations which are easily understood by other doctors
such as BP, UTI could be used.

Types of Medical Records

Medical records could be maintained as paper based (physical)
records or computer based (electronic) records. Whether the medical
records are paper based or computer based, they could be maintained
as family medical records or individual medical records.

Physical or paper based medical records

Family medical records - As family doctors usually care for the

whole family, maintaining a family record is reasonable and useful.
The family file or folder will be filed under the name of the head of
the household. The family folder will contain information about each
member of the family in a separate page or set of pages within the
same file.
The first form in the family folder is the family registration form that
is recorded at the first visit. It will contain demographic data about
the family.
The next will be the family genogram which is an important data
base about the family that can be easily placed within the medical
record. The family genogram is a three generational family tree that
provides a structural, historical and factual family diagram. Although
not necessary for every family, it is drawn by the family physician
when there is a need to identify disturbed family relationships and to
identify inherited disorders and potential problems for which
preventive action could be taken.
In the family genogram (Fig. 1), ages, marriages, divorce, chronic
disease and deaths as well as interpersonal relationships are
recorded. Sibling order is from left to right with the oldest sibling on
the extreme left and the youngest on the extreme right. If only the
ages are mentioned, the date on which the genogram was drawn is
necessary, so that the ages could be adjusted over time. Symbols and
abbreviations used should be simple, so that at a glance, the
information can be retrieved.
The purpose of the family registration form and the family genogram
is to provide as much data as possible about the family, which could
have an impact on the health of different members of the family.

Mr. S.M. (No. 21) - 01.12.10

Symbols Abbreviations

□ male fBP - Hypertension

OO female MI Myocardial infarction

 X dead MD Manic depressive

marriage, offspring OA Osteoarthritis

disturbed relationship CVA - Cerebrovascular accident

close relationship Su Suicide

Ca br Carcinoma breast

S.M. - Name of Index Patient

Fig. 1 FAMILY GENOGRAM

The advantage of family records is that interrelated family problems
can be identified and treated. It has been reported that frequent
consultations for pain and anxiety related symptoms in the patient
and the family, could precede depression in the index patient by
almost a year.

The disadvantage of family records is that they become too bulky

and retrieval of individual records more difficult as time goes on.

Individual medical record - This is the ideal, because the specific

problems unique to a particular individual are recorded in it.
Individual medical records are also more accurate, comprehensive
and easily retrievable.

The types of medical records and the format of the medical record
depends on an individual doctor’s preferences and requirements. An
ideal office record for the family physician to use, is the Problem
Oriented Medical Record (POMR) which is a well structured
individual medical record.

The Problem Oriented Medical Record (POMR)

The POMR was developed by Dr. Lawrence Weed in 1969. The

concept of a problem oriented record was originally devised for
hospital records, but with slight modification was found to be an
excellent foundation for an office record. The POMR is sometimes
also referred to as a Patient Oriented Medical Record, to emphasize
the individuality of the record as it contains data specific to an
individual patient only.

The POMR achieves its maximum potential in the hands of the

family physician. It is useful in communicating facts about the
patient to a doctor who is acting for the regular doctor and also to
other members of the health care team. This is common in countries
such as the UK and USA where there are group practices and also a
number of health professionals such as practice nurses or nurse
practitioners providing some aspects of patient care.
The POMR which contains a problem list is useful, when the need
arises to send the patient to another physician. The consulting
physician who receives the problem list of the patient, will get a
complete picture of the patient’s other medical problems as well as
social and psychiatric problems. Sometimes the flow sheet giving the
details of the follow up on chronic diseases, may be useful for the
specialist physician who is consulted.

The ideal structure of a medical record is described in this chapter,

but each doctor could devise his or her own depending on the
practice requirements and individual preferences.

It would be convenient to have the POMR to be of a size that could

easily be stacked sequentially inside the shelf of a cupboard. The
POMR will have a folder or outer cover with a set of forms inside.
The outer cover should have the patient’s name, address and the
registration number. The forms inside the folder of which there could
be as many as five as shown below and may be structured to record
different types of information.

Basic data sheet

Problem list
Progress Notes / Clinical Notes
Flow Sheet
Laboratory data sheet
Child Health Development Record

All medical records should have a Basic data sheet, Progress Notes /
Clinical Notes and a Laboratory Data Sheet, while the other forms
could be used where relevant.

Basic data sheet - This will be completed at the first consultation

and will contain the basic socio-demographic information about the
patient. It could be completed by the doctor or the receptionist at the
first consultation.

The basic data sheet should include some or all of the following:-
Name, sex, date of birth, address, telephone number,
Occupation, marital status, family members and relationships,
Past medical history, family history of illnesses,
Record of immunizations,
Drug history, allergies etc

Problem list - The problem list provides an overview of the patient’s

present and past state of health. It is a “snapshot” of the patient’s
present and past health and potential health risks. The problem list is
unique to each individual.
The items on the problem list (Fig. 2) may be a symptom such as
urticaria due to a food allergy or a diagnosis such as diabetes. It
could be a social problem such as spouse abuse or an economic
problem such as poverty. The problem may be something that is no
longer existent such as a hysterectomy in a woman who suffered
from menorrhagia. This will give an indication to the doctor that it is
no longer necessary to get a menstrual history from the patient.

The problem list is a changing one and not static. Old problems may
have resolved while new ones are added on. The problem list is
useful as the doctor sees at a glance what the patient’s current and
recurrent problems are. A doctor acting for the regular doctor would
be able to get a complete picture of the patient, so that he or she
could manage the patient’s presenting problem, while keeping the
whole person in perspective.

It should be remembered that sometimes there may be no definite

diagnosis. The entry in the problem list in such instances, should
only describe what is known about the illness at its current state of
development. Example of a Problem List is shown in Table 1,

TABLE 1. PROBLEM LIST NAME - Mrs. F.G. (G105)

Date Problem Comments

3. 3. 14 Urticaria due to food allergy
2. 5. 14 Black eye wife abuse
16. 6. 14 Abscess I&D
started on dietary Mx
22. 11. 14 Diabetes
& metformin 500 mg bd
19. 4. 15 Menorrhagia
20. 5. 15 Hysterectomy
12. 7. 15 Anxiety ?
Anxiety &
10. 8. 15 Tricyclic antidepressants
Depression
Diclofenac sodium and
12. 1. 15 Neck pain
Omeprazole.

Progress notes or clinical notes - This is a record of what happens

at each consultation or doctor-patient encounter. It can be described
as the note the doctor writes to him or herself for the next time the
patient is seen.

What happens during the consultation could ideally be recorded

using the SOAP mnemonic.

S (Subjective) - Subjective information will be the symptoms and

feelings as described by the patient. What is recorded will be the
patient’s reason for encounter or reason for coming. It is an
interpretation of the problem from the patient’s point of view.
O (Objective) - Objective information includes the doctor’s findings
on physical examination and all other factual information such
as the results of investigations and so on.
A (Assessment) - Assessment of the problem or diagnosis.
Sometimes in general practice, a definitive diagnosis may not be
 possible. The assessment of the problem could then be recorded
in symptomatic terms or in physical, social and psychological
terms.
P (Plan of management) - This includes investigations, prescription,
counselling, patient education, preventive care, minor surgery,
referral and so on. Copies of referral letters and replies from the
consultant could also be kept within the folder.

At the follow up visit for an acute illness, all four categories in the
SOAP format need not be used. Eg. If a child is brought for follow
up of an acute URTI, the progress notes need only mention - no
symptoms, lungs - clear, child well.

Flow sheet - The flow sheet is very useful for the ongoing care of
chronic diseases such as diabetes mellitus and hypertension. The
flow sheet is helpful as the doctor need not go through pages of
progress notes, when a patient is visiting the doctor for a monthly
check up of a chronic illness.

The flow sheet could be a preprinted form with horizontal and

vertical columns. On the flow sheet the doctor, could enter at each
visit, the date, and alongside the date in each column write the FBS
value, weight, BP, medication given etc. (Table. 2.)

NAME: Mr. M. P. No: P 55 DIAGNOSIS : Diabetes mellitus

Date Weight BP FBS HbA1c Urine for Treatment
(Kg) (mg/d (%) Microalbu
l) min
5.4. 15 58 130/86 230 - - Gliclazide
80mg bd
6. 5. 15 58 130/90 180 7.8 - Gliclazide
80 mg bd
10. 6. 57 140/90 150 - 19.3mg/l Gliclazide +
15 Enalapril
8. 7. 15 57 130/84 132 6.2 ”

8. 8. 15 56 120/80 150 - - ”

Table. 2 Flow Sheet

Laboratory Data - A separate form to record the laboratory data is

very useful. When a patient brings the results of investigations, and
X ray reports etc. the doctor or nurse could enter the relevant
findings in the laboratory data sheet and allow the patient to keep the
reports. If time and space permits, the entire report should be entered
in the laboratory data form, while only the relevant information is
briefly mentioned in the progress notes under objective information.
Child Health Development Record (CHDR) - The child health
development record is a useful addition to a child’s record. When a
child is brought, the doctor may use the opportunity to monitor the
child’s growth by weighing the child and recording the milestones
and mental and physical development of the child. The doctor could
also record the immunizations and check whether the child has had
the age appropriate immunizations carried out to date.

The doctor may keep a photocopy of the Growth Chart and

Immunization Chart within the Medical Record maintained for the
child in the clinic. Alternatively, the family doctor may make the
relevant entries in the Child’s own CHDR brought by the parents that
had been given by the hospital where the child was born.

Ethical issues with regard to medical records

This is an important aspect that needs to be looked at carefully. This
has become very important with the advent of computer based
medical records over the past 3-4 decades. However, whether paper
based or computer based, the ethical issues are the same although
handled somewhat differently.
Confidentiality - Medical records in whatever form should be
maintained as confidential documents and should not be accessible
to anyone other than the doctor. However, in group practices or
where there are several members in a health care team, there will be
others such as nurses who will have access to the medical record as
well. The general principle should be that the medical record should
be accessible only to health care professionals who are directly
involved in the care of the patient. Even the receptionist who makes
appointments and makes the medical record available to the doctor,
whether it is paper based or computerized should not have access to
the medical information within it.
Should patient’s have access to their own records?- Patients are
entitled to have access to their own medical records. In the UK,
patients have had legal entitlement to see their records since 1991,
and many have held their own paper based records. In Sri Lanka,
many hospital clinics encourage the patient to bring an exercise book
in which the patient’s health information is recorded. In Family
Practice, if a patient requests to be shown his or her record or wishes
to receive a copy, the doctor is obliged to do so.
Controversy exists as to whether having access to their medical
records could have a good or bad effect on patient care. Some studies
have found that patients who have access to their medical records,
have a better understanding of health problems and comply better
with medical treatment. Access to their own medical records could
assist in shared decision making and help patients to manage their
own medical care. It has also been found that patients are less likely
to sue the doctor for malpractice, when they have access to the
medical record.
In the UK, patients have had legal entitlement to see their records
since 1991, and many have held their own paper based records. For a
patient to have his or her medical records is also useful when a
patient has to go into an emergency care unit or when the patient
falls ill while visiting another town or country. In Sri Lanka, many
hospital clinics encourage the patient to bring an exercise book in
which the patient’s health information is recorded. Unfortunately this
practice is not followed in outpatient departments of state hospitals
where only a prescription card is maintained.
A recent development with regard to a patient held record available
in some countries is, where the patient carries his or her personal
health information in something like a credit card, called a Smart
Card. The patient could carry this in a purse or handbag and when he
or she seeks medical care, a summary of his or her health
information could be read in any medical centre which has the
appropriate machine for reading smart cards. Patient access to on-
line primary care electronic records is also being developed in the
UK.
Organization of a Recording System for easy access and
retrieval

Filing system - An efficient filing system is essential to ensure that a

patient’s medical record can be easily retrieved when needed. There
is no point in having well structured records which cannot be found.
The alphabetical filing system is simple and easy to use. The names
are entered alphabetically in a register, which has 26 marked
subsections for each letter of the alphabet. Each patient will be given
a registration number which starts with the first letter of the surname
followed by a number given in serial or chronological order. The
patients could be given cards with their registration numbers with
instructions to bring them when they come to visit the doctor again.
The number on the card will enable the files to be retrieved easily
without looking at the register, provided the files have been stacked
in serial order on the shelf.

Other registers in the practice

In addition to the Registration Book in which the patient’s date of
first registration and relevant record numbers have been written
down, there are a few other registers that family doctors could
maintain in the office. These are the following
- Age sex registers
- Disease registers
- Immunization Register
- Depo Provera Register
Age sex register. This is a register in which the name of each patient
has been entered according to the sex and date of birth. In this
register there will be a separate page for either sex and for each year
of birth. Eg. all female patients born in 1971 will be recorded on the
same page in the register. All males bom in 1981 will be on another
page and so on. Each entry in the register will have the patient’s
name and registration number, so that a particular patient’s record
can easily be retrieved.
The importance of maintaining age sex registers is that retrospective
surveys can be easily carried out. Supposing the doctor wants to
study health problems of the elderly (>65 years), all that needs to be
done is to identify in the register, the medical records of all patients
who had been born before a certain year. If the survey is done in
2005, all those born in or before the year 1940 will be over the age of
65 years and this will be the study population whose records could
be retrieved for the survey. Similarly a doctor could study the extent
of malnutrition in children under five years or study the prevalence
of UTI in women of reproductive age and so on.

Disease registers These registers will also help doctors to carry out
retrospective studies on patients with chronic diseases such as
hypertension and diabetes.

Immunization register - This register will be helpful to the doctor to

know whether some patients have defaulted and not had their
immunizations on time.

Depo Provera Register - could alert the doctor to patients who have
missed coming for the three monthly injection.

The last two registers would be useful in sending reminders to

patients who have defaulted. The registers are also useful for the
doctor to make an estimate of the quantity of vaccines or vials that
have to be purchased in the ensuing months.
Electronic or computer based medical records :- In this modem
era of science and technology, computerization of medical records
has come to stay. Most general practices in the UK and Australia
have electronic medical records. Even in Sri Lanka, the university
family medicine clinics and a few GPs use computer based medical
records. Patient attitudes to computerized medical records is also
changing and becoming acceptable to patients. Some patients believe
that the doctor who maintains computer based medical records, is
also up to date with regard to medical knowledge.

Computer based medical records have advantages and disadvantages

over paper based records.
Advantages :
1. Requires less space. A large amount of data could be stored in
the computer.
2. Retrieval is easy, quick and efficient.
3. Confidentiality is better and is guaranteed if the doctor enters
 the data in the presence of the patient and remembers to close
the previous patient’s record before the next patient comes in. A
password can also be used to protect the patient’s records.
4. It is easier to do research using electronic medical records.
5. Preventive care and identification of risk factors are also made
easier as the programme could be made to bring up prompts to
remind the GP that a BP check has not been done for one year
or that the patient is due for the next Depo Provera injection.

Disadvantages :
1. Expensive to set up
2. Need expertise and training to use
3. Could disturb the doctor-patient relationship as eye contact with
the patient is relatively less.
4. Computer viruses may destroy all the records and this could be
prevented by using anti virus software.
5. Regular back up is essential to overcome the risk of losing
records due to hardware failure or physical damage to the
computer.

Use of computerized medical recording systems

1. Research
2. Clinical audit
3. Collection of statistics on morbidity, immunization, referral etc.
4. Recall of patients for preventive care or patients with a chronic
illness who could benefit from a new treatment.
5. Printing of prescriptions, referral letters, patient education
leaflets, medical certificates.
6. Access to authoritative sources of reference eg. disease
management protocols, drug data bases such as the British
National Formulary (BNF) and MIMS which is an index of
information on medical products.
7. Faster, easier and safer on-line communication between GP and
the hospital with regard to referral, out-patient bookings,
transfer of discharge information and reporting of test results.
8. Could have built in prompts or warnings for the following :
- BP check, HbAlc, pap smear
- drug interaction warnings
- drug use in pregnancy and breast feeding
- drug use in sports
- substance abuse warnings
9. Clinical tools could be incorporated such as
- BMI calculator
- Coronary risk calculator
- Paediatric growth charts
- Respiratory function calculator
10. Electronic links to laboratories and radiology departments
which enable electronic transfer of pathology test results,
radiology reports and images to the computer on the GPs desk.
All the above mentioned functions are characteristics of
sophisticated electronic medical records. One such package popular
among GPs in Australia is the Medical Director. Electronic medical
records used in office practice in America include the EMC
(Electronic Medical Chart) and Alteer Office. Turbo-doc and
zCHART are systems that can be used on a palm held computer or
pocket PC. Smart Doctor is one developed by physicians for
physicians. All such electronic patient recording systems available
commercially are very costly and more suitable for developed
countries. It is important for countries in Asia to develop their own
medical recording systems suitable for use in the local context.

Chapter 18
 ETHICAL AND LEGAL ISSUES
IN FAMILY PRACTICE

Ethics is the science of moral principles. Ethics lays down standards

of conduct of individuals or groups of individuals. It is composed of
concepts of values such as what is “good” or “bad”, what is “right”
or “wrong”, what is “desirable” or “undesirable”, what is “fair” or
“unfair” and so on.

Ethics in other words imposes conformity to an agreed set of norms.

Medical ethics is ethics in relation to the practice of medicine. The
fundamental principles with regard to medical ethics laid down in the
Hippocratic Oath, are valid even today and many ethical principles
are derived from it.

The legal system in a country and the code of ethics or code of

conduct laid down for the medical profession, could vary slightly
between different countries. If any doctor violates the rules and does
not conform to the code of conduct laid down for registered medical
practitioners, the licensing and disciplinary body for doctors in that
country has the right to take disciplinary action against a particular
doctor.

In Sri Lanka the licensing body is the Sri Lanka Medical Council
(SLMC). It is mandatory for all medical and dental practitioners to
be registered with the Medical Council to practice their profession in
Sri Lanka. The Sri Lanka Medical Council has the authority to take
disciplinary action against a registered medical practitioner in the
following circumstances.
1. The doctor has been found guilty of a criminal offence by a
Court of Law.
2. The doctor has been found guilty of serious professional
misconduct by the SLMC.
3. Physical or mental incapacity to practice medicine
4. Evidence of seriously deficient or incompetent performance

When a complaint is received by the medical council, depending on

the gravity of the offence, a formal inquiry will be held by the
Professional Conduct Committee (PCC). The course of action taken
by the SLMC may be to
a. Issue a reprimand or warning and conclude the case
b. Suspend registration (place the doctor on probation by
postponing final action)
c. Cancel registration (erase the doctor’s name from the medical
register)

What is a criminal offence?

Criminal offence refers to malpractice according to the law. Doctors
should be familiar with the law of the land and abide by the law. A
doctor found guilty of a criminal offence could be charged in a court
of law and may be fined or imprisoned. Such offences may be for
example, the termination of pregnancy which is illegal in this
country.

What is serious professional misconduct?

The booklet published by the Sri Lanka Medical Council in year
2000, quotes a definition of “Serious Professional Misconduct” by
Lord Justice Lopes (1894) as follows:

“If a medical man in the pursuit of his profession has done

something with regard to it, which will be reasonably regarded as
disgraceful or dishonourable by his professional brethren of good
repute and competency, then it is open to the Medical Council, if that
be shown, to say that he has been found guilty of infamous conduct
in a professional respect.”

Therefore, if doctors want to safeguard themselves from being

accused of professional misconduct, they should act in a manner
which conforms to the code of ethics laid down for doctors by the
medical profession in that country.

General guideline on medical ethics

The following code of conduct provides a guideline for doctors to
practice medicine within the ethical norms expected of a medical
practitioner.
• Act with medical responsibility
• Obtain consent before examination and treatment
• Maintain confidentiality
• Take care in the issue of medical certificates
• Avoid prescribing drugs of dependence
• Avoid derogatory conduct and ethical malpractices

Medical responsibility The doctor should have a sense of medical

responsibility.
Whether a doctor practices in the private sector or the government
sector, he or she receives a fee for service. In the private sector, the
doctor receives a fee directly from the patient and in the government
sector the doctor receives a salary from the state but indirectly from
the patient who is a tax payer. Therefore, the patient has a right to
expect a good standard of compassionate and competent care from
the doctor whom he consults.
If the doctor has not acted in a responsible manner and has not been
competent according to the standards of care expected, the doctor
could be accused of medical negligence. The patient could take the
doctor to court and claim damages from the doctor.
The patient has to prove that as a result of the doctor’s treatment or
neglect, unnecessary pain and suffering had been caused to him or
her. If the doctor is found guilty of medical negligence, the doctor
has to pay the damages.

In addition to the legal action taken against the doctor, the doctor
also faces the possibility of the Medical Council taking disciplinary
action against him or her.

How could doctors act responsibly and avoid being accused of

medical negligence?
In order to avoid litigation, doctors should exercise proper standards
of care. Doctors should treat their patients with compassion and
concern, establish a good patient-physician relationship, take an
adequate history and find out all about the patient’s illness. The
doctor should find out whether the patient has any other medical
problem, is taking any other medications or is allergic to certain
drugs.
Care should be exercised during the clinical examination. All
relevant parts of the examination and any tests that are necessary
should be done, which would help in the diagnosis of the patient’s
problem. Doctors however, should not practice defensive medicine
and request unnecessary investigations to make sure that no
diagnosis is missed in order to avoid litigation. Doctors should
instead, use their clinical skills to the maximum and order only the
tests which are necessary in relation to the clinical findings to
confirm or exclude a diagnosis.
In the management of the patient, the doctor should be competent
and if the disease needs specialised care such as surgical treatment,
the doctor should not hesitate in referring that patient to the
appropriate specialist. Doctors should not treat beyond their level of
competence and should be aware of their own capabilities. The
doctor should always review the diagnosis and seek an opinion from
another professional colleague when in doubt.
All doctors should maintain medical records. Then, if the doctor is
taken to courts for medical negligence, the line of action adopted in
the treatment of the patient could be traced, and this would help
establish credibility in the eyes of the law.
In countries such as the USA, litigation is very common and all
practising doctors obtain a medical insurance (medical defence) to
safeguard themselves. Even in Sri Lanka, doctors have been taken to
court in recent times. Some doctors have already covered themselves
with medical insurance.

Consent - This is an important ethical aspect to be considered.

Consent has to be obtained before examination, investigation and
treatment. Consent is implied when a patient consults a doctor of his
or her choice. However, consent is necessary if the patient has to
undergo an invasive procedure such as a rectal or vaginal
examination (PR or PV) or one that encroaches on the patient’s
modesty such as a breast examination. When the patient has to
undergo an invasive investigation such as endoscopy or any
hazardous treatment, it is important to obtain consent from the
patient after the patient has been fully informed of the benefits and
the risks involved in the proposed investigation or treatment. Once
the patient has been adequately informed and the patient has given
consent either verbally or preferably in writing, it can be said that the
doctor has obtained informed consent.

Written informed consent is mandatory in the following instances :

* Examination at the request of a third party such as an
employer or for insurance purposes.
* Special situations such as victims of rape
* Clinical trials and research projects
* Invasive investigations and procedures such as endoscopy or
ones that carry risks
* Where a disability or disfigurement is likely after surgery such
as amputation or mastectomy.
* Hazardous treatment and all surgical procedures
An exemption to informed consent is when a doctor acts in an
emergency to save a person’s life.

When the patient is a child, informed consent has to be obtained

from the parents. Problems with regard to obtaining consent arise
when the patient is a teenager who is still a minor, and has consulted
the doctor on his or her own. A young person under the age of 18 can
consent to treatment provided they can understand the nature,
purpose and possible consequences of the proposed treatment. A
young patient should be encouraged to involve the parents when
making decisions.

If a competent young person under the age of 18 refuses treatment,

the court allows doctors to provide treatment with consent from a
parent or guardian or following a court decision. When the patient is
not competent to make an informed decision, as in the case of a
mentally retarded patient, the law allows doctors to treat without
consent. However, the treatment should be in the patient’s best
interests and views of the closest relative or guardian should be
sought to assess the patient’s best interests.
Where treatment has been refused by an adult patient or relatives, it
is essential to record that the patient has refused treatment. This may
include refusal to get admitted to hospital for a condition which
needs investigation and treatment in hospital and one which may
lead to serious consequences if treated at home. In such instances the
doctor should record the patient’s refusal as a safeguard. The
patient’s refusal for admission may be because of personal problems
at home, which the patient considers as being more important than
receiving appropriate treatment for the disease in hospital. Therefore,
the doctor should also respect the patient’s autonomy and explore
possibilities of an alternative plan of management which is not the
optimal course of action, but one that is the best possible course of
action in the circumstances. The problem of the non-compliant
patient is not uncommon in general practice and should be dealt with
appropriately in this manner.

Maintenance of professional secrecy or confidentiality

In the course of a professional relationship between a doctor and his
or her patient, confidentiality is implied. Breach of confidentiality is
a breach of this contract and the patient has grounds to take the
doctor to court. In some countries, maintenance of confidentiality is
a legal obligation required of the doctor.
The patient divulges confidential information to the doctor with the
hope that such disclosure will help the doctor to correctly diagnose
the condition. The doctor therefore should maintain professional
secrecy or confidentiality and not divulge what has been revealed
during the consultation to anyone else without the patient’s
permission.
There are a few exceptions to maintenance of confidentiality. They
are:
* Shared confidential information with other doctors or specialists
who are consulted for a second opinion or with other health care
workers involved in the care of the patient. This could be with the
patient’s consent.
* When compelled to do so by a court order. The order has to be
made by the judge and the doctor should take care to disclose
only the exact information required and also make known his
 objections to having to divulge confidential information.
* Doctor’s duty to society where the doctor gets to know that a
serious crime has or is about to be committed or there is a danger
to society. In Sri Lanka, this may be necessary under the
Prevention of Terrorism Act. If a doctor gets to know that a
dependent such as a child has been the subject of abuse, it may be
necessary to inform the authorities.
* When the health and safety of the public is at stake. Eg.
notification of infectious diseases which is a statutory duty
required of a doctor. But this could be done after informing the
patient that it is necessary to do so. Notification of poisoning
under the factories ordinance and notification of births and deaths
are other statutory duties of doctors.
* For purposes of a medical report to a third party like an employer
or insurance company, but in this instance the patient’s consent
should be obtained.
* When it is necessary in the patient’s own interests, that a relative
should be told about the illness eg. a patient who is
contemplating suicide.

Medical Certificates - Care should be taken in the issue of medical

certificates as these are legal documents. If a false medical certificate
is given, it is an offence. The medical certificate should be accurate
and carry the date of the medical examination and the period of
incapacity from work. The nature of the illness should be recorded
with the patient’s consent.

Where death certificates are concerned, if there is a doubt about the

cause of death, a doctor should not give a death certificate but ask for
an inquest.

A doctor’s signature is required on various other certificates on the

presumption that the truth of a statement certified by a doctor can be
accepted without question. Therefore, doctors are expected to
exercise care in issuing certificates and similar documents and not
certify statements that they have not taken the trouble to verify as
being true. A doctor who certifies a statement that is untrue or
misleading or otherwise improper may be liable to disciplinary
proceedings.

Avoid prescribing drugs of dependence - There should be no abuse in

the prescription of drugs of dependence except for bona fide reasons
nor should a doctor supply such drugs to unauthorized persons. This
would be a breach of the law.

Avoid derogatory conduct and ethical malpractices - The doctor

should avoid derogatoryconduct. He should avoid the seven ‘A’s
which are -
• Abortion.
• Association with unqualified persons.
• Alcoholism - the doctor should not work under the influence of
alcohol or exhibit violent or aggressive behaviour.
• Abuse of privileges conferred by custom eg. breach of
confidentiality or exertion of influence on a patient for financial
favours or any other favours.

• Adultery - the doctor should not enter into improper relationships

with patients who are under his care.
• Advertising and publicity should be avoided. To appear on
television or radio, the discussion should be a medical subject of
interest to the public and the doctor should preferably be from a
recognised institution. Qualifications and designation should be
mentioned only in the interest of authenticity.
• Advantage - Treatment given to the patient should be in the
patient’s best interest and not for the doctor’s financial
advantage. Therefore, unnecessary investigations or treatment
should not be done for financial advantage. The doctor should not
engage in fee splitting with colleagues to whom he has referred a
patient to.

Therefore, if a doctor wants to work within ethical norms and avoid

being accused of professional misconduct, the doctor should act with
medical responsibility, obtain consent, maintain confidentiality, be
careful in the issue of medical certificates, not prescribe drugs of
dependence except for bona fide reasons and avoid other forms of
derogatory conduct and ethical malpractices.

Principles of Medical Ethics

While conducting oneself in a professional manner as outlined
above, doctors are guided by certain basic principles of medical
ethics.
The basic principles of medical ethics are -
• Patient autonomy
• Beneficience
• Non maleficence
• Justice

Patient autonomy - have respect for the patient as a person and

respect the patient’s autonomy.

Beneficience - Act in the best interests of the patient. Do what will

benefit the patient because the primary responsibility of a doctor is to
the patient. This means respecting the patient’s autonomy and taking
into account the patient’s wishes and values. Doctors should explain
truthfully to patients and relatives, about the potential benefits, risks
and effects on prognosis of the proposed investigation or treatment
without misrepresenting the facts, so that the patient and relatives
can make an informed decision.

Non maleficence (Do no harm) Therefore, doctors should be

competent and update their knowledge by keeping up with recent
advances in medicine. It also means that doctors should not give
ineffective and harmful therapies or act selfishly or maliciously
when treating patients.

Justice - Be fair by all which means that people in the same situation
should be treated equally. This becomes important when it comes to
allocation of health resources in health care settings where resources
are limited.

The ethical principles outlined above may sometimes be

contradictory to each other, for example respecting one patient’s best
interests may conflict with fairness to others (justice). Maintaining
confidentiality of a patient may conflict with protecting another
person from harm. Also respecting the patient’s autonomy may mean
that what the patient wants could cause serious harm to him or her
and would not be in the patient’s best interests. Sometimes patient’s
requests may be against the doctor’s own moral and religious
convictions and beliefs. When there is a conflict between the
doctor’s religious convictions and the patient’s requests eg.
contraception, the doctor may hand over the responsibility for that
patient to someone else.

Ethical or moral dilemmas in clinical practice - Doctors in

clinical practice are faced with situations which pose dilemmas as to
what is the correct thing to do, what is right or wrong, fair or unfair
and so on.

Examples of such dilemmas are given below -

• How do you treat the woman who may have contracted a

sexually transmitted disease from her husband who has been
unfaithful ?

• When do you decide to withhold unnecessary and uncomfortable

treatment from a terminally ill patient whose death is inevitable ?

• Should you give an injection to a mentally ill patient against his

wishes?

• Should the doctor tell the parents that a teenager has sought
abortion or contraceptive advice?.

There are many such moral and ethical dilemmas that doctors come
across in clinical practice, for which there is no absolutely correct
answer as to what is the right thing to do. In deciding what to do in
case of ethical dilemmas, doctors need to be aware of ethical
principles and be guided by their conscience. Considering human life
as sacred, and having values such as integrity, honesty,
trustworthiness, respect for colleagues, truthfulness, altruism, being
accountable for one’s actions and being competent and up to date are
other characteristics that are important in ethical medical practice.

The demand by society for quality medical care, patients’

expectations of doctors and patients’ rights play an important role in
modem clinical practice. When third parties are paying for the
patients’ care, another dimension is added to the physician’s dilemma
of balancing patients’ rights, personal beliefs and loyalty to the third
party who may also be the doctor’s employer. In family practice,
ethical dilemmas could also arise due to the fact that the same family
doctor is treating different members of the same family and different
families living in the same locality over a long period of time. To
discuss these in more detail is beyond the scope of this chapter and
for the same reason many other moral dilemmas met with in clinical
practice have also been left out.
 Chapter 19

QUALITATIVE RESEARCH IN MEDICINE

Introduction

Bio-medical research has traditionally used quantitative methods of

inquiry. Many doctors are yet unaware of qualitative research which
has made its debut into the field of medicine over the past three
decades. Therefore qualitative research methods hitherto used in
sociological research is now being used in medical research although
it took a long time for such methods to be accepted by the scientific
medical community.

Since the mid 1990s, the BMJ has been publishing articles based on
qualitative research and this reached a peak of in 2002. The first
article on Qualitative Research in the Celyon Medical Journal was in
2003 by Sumathipala, Siribaddana and de Silva. Subsequently an
article on Qualitative Research: how to do it by the last author of the
above article was published in Medicine Today, 2005. This was
followed by an article on ‘Patient expectations and satisfaction with
ambulatory care settings’ in the Sri Lankan Family Physician 2007 by
de Silva, Mendis and Ramanayake. Even in 2011, a debate was going
on about the need for the BMJ to publish qualitative research articles
which shows that it continues to have difficulties in gaining full
acceptance in medical scientific circles.

The current situation is that qualitative research has come a long way
and is being recommended for health services research and as well as
to be used alongside randomized controlled clinical trials. It is
believed that combining randomised controlled clinical trials (RCTs)
with both quantitative and qualitative observational designs will
generate information to help in the successful implementation of
effective interventions in natural settings as well as allowing further
refinement of interventions. There are also systematic reviews of
published qualitative research studies available in prestigious
journals as given at the end of this chapter.

Quantitative Research and Qualitative Research. How are they

different?

In quantitative research, the study design is structured so that two

people doing the same study independently reach the same
conclusion. The data are reduced to numerical values and analysed
statistically, so that the findings can be generalized. For example, a
study on cancer may determine the cancer which has the highest
prevalence by collecting data from a representative sample and then
generalizing the findings to the whole population. These findings are
useful to health policy planners and would alert individual clinicians
to the early detection of cancer in their practice populations.

Individual clinicians are also interested to know evidence based

medicine from RCTs, systematic reviews etc which may show that
one drug is superior to another in the treatment of certain diseases.
However, this type of research only gives part of the total picture
because even with evidence from well conducted research that a
particular drug is useful, the desired outcome expected depends on
adherence to treatment by patients. The reason that mortality from a
particular disease with the best drug does not change is due to the
fact that patients are individual human beings with their own
perceptions, likes and dislikes, fears and uncertainties and so on.
Doctors too may be partly responsible due to variations in
prescribing behaviours, doctor patient communication, cost of
treatment etc. So medical care using drugs based on the best
available evidence can fail as we are dealing with human beings who
may respond in different ways to the drugs given, have feelings,
fears and dislikes of certain forms of medical treatment. Some who
will not change their lifestyles in spite of overwhelming evidence as
to the beneficial effects. Therefore an individual clinician may be
interested in finding out why some people do not comply with
treatment, how people in a particular culture feel on hearing the bad
news of cancer and so on. Such information can only be obtained
through a qualitative study.

Therefore in medicine, qualitative research methods become useful

when one needs to want to find out the why and the how, in addition
to the how many or how often that you find out from quantitative
research. Qualitative research is useful where one needs to study a
range of phenomena such as thoughts, feelings, processes, pain,
interactions between people and so on. Taking the cancer example,
one will be able to find out the emotional response of a patient and
family on receiving bad news of cancer and their feelings about the
medical care received.

In the UK, cardiovascular disease accounted for 170,000 deaths per

year in 1999 and in a bid to reduce deaths, the guidelines of the
National Service Framework required GPs to treat
hypercholesterolaeamia. However, a survey found that lipid control
was adequate in only 17% of those with established coronary heart
disease while only 3% of those at high risk were receiving lipid
lowering drugs. Qualitative studies have found that lack of
compliance by patients and wide variations in prescribing behaviours
of doctors was responsible for these findings. Another study
investigated GPs views about guidelines and barriers to use of
statins. Among the barriers identified were the cost, increase in the
workload, being unhappy about medicalisation of normal people etc.
The study concluded that guidelines should take into account not
only evidence but also the practical problems involved in
implementation of the recommendations.
Qualitative research methods are therefore useful to identify
problems in implementing evidence based medicine in clinical
practice and to develop potential solutions to improve practice.
Systematic monitoring and reflecting on the process and outcomes of
change also needs to be carried out. The term Action research is also
used to describe this method that adopts a participatory approach by
working with rather than on subjects and is increasingly being used
in health service research.

A systematic review of qualitative research articles published in

countries around the world such as USA, UK, Brazil, Sweden,
Canada, New Zealand, Denmark, Finland, Ghana, Iran, Israel,
Netherlands, South Korea, Spain, Tanzania, and Thailand on lay
perceptions of hypertension and adherence to drugs was carried out
by Iain Marshall and others in 2012. The systematic review found
that people across all continents believed that hypertension was
principally caused by stress and produced symptoms, particularly
headache, dizziness, and sweating. Participants commonly perceived
that their blood pressure improved when symptoms abated or when
they were not stressed, and stopped taking their medication when
they felt better. They also disliked treatment and its side effects and
feared addiction.

Qualitative Research

Qualitative research is based on the observation and description of

phenomena. This is nothing new in the history of medicine. Clinical
observation of naturally occurring phenomena have preceded
laboratory experiments and led to advances in medicine eg. The
breakthrough in small pox vaccination in the 18 th century followed
the clinical observation by Jenner that people who had cowpox did
not develop small pox. Observation of the natural history of disease
led to the description of sinus arrhythmia as being a normal
physiological phenomenon by James Mackenzie in the 19th century.

By qualitative research one tries to understand human behaviour

from the subjects own frame of reference . In other words,
Qualitative research tries to find out what subjects make of events
and the meanings they attribute to such events in the form of
feelings, emotions etc.
 Qualitative research starts with observations that will provide data
which could be used to generate a hypotheses. These hypotheses
could be tested further by a quantitative study. The two together will
help to increase the breadth, depth and scope of the research. To give
an example, a study on patient expectations and satisfaction with
ambulatory care consultations was conducted in two stages. The first
was a qualitative study to find out what patients expect from doctors.
The second stage of the study was quantitative where a questionnaire
was constructed based on patient expectations found out through the
qualitative study. The questionnaire was given to a sample of
ambulatory patients soon after seeing a
doctor to assess the degree of satisfaction with the consultations.
The second stage used quantitative research methodology and
statistical analysis.

Therefore quantitative and qualitative research are complementary to

each other and
could be used together in one study to enrich the research. The
findings from a
from s qualitative study used alongside a RCT can be converged to
give
the total picture with regard to a new intervention.

The differences between Quantitative research and qualitative

research is given in box 1.

Quantitative research Qualitative

research

Scientific method Naturalistic

Data are numerical Data is descriptive
Reductionistic- subject reduced to variable Holistic - subject
part of
a greater whole
Standardized data collection instruments Researcher as
instrument
in data collection
Categories precede data analysis Categories follow
data
analysis
The differences between quantitative and qualitative research have
been described thus.

Quanitative research is a mile wide and an inch deep

Quantitative researchers count but don't think while qualitative
researchers think but don't count.

Guidelines for the qualitative researcher.

No preconceptions or theories
There are no preconceptions or theories or hypotheses as this would
lead to bias in the observation of phenomena or happenings that one
wants to observe or investigate. If the objective of the study is to find
out about primary medical care as it is delivered in an OPD, it is
inappropriate to go to the OPD with a preconceived set of ideas and
a standardised questionnaire. This will narrow the information
collected and be biased to the researchers preconceived ideas as to
what is happening in the OPD. For the qualitative researcher, the
approach may be a general question such as " what is it like to take
treatment from the OPD of a state hospital"

Individuals are studied in depth.

All participants in a process will be studied in depth. Taking the OPD
example, inquiries should be directed at patients seeking treatment as
well as the doctors treating them.

The individual is studied in the natural setting and in their normal

routine and normal conditions.so that qualitative research is
sometimes referred to as naturalistic method of inquiry. Extraneous
influences should also not be allowed to intervene.

Understanding rather than measuring.

Qualitative research seeks to find out how a person thinks, feels and
acts rather than making numerical measurements which are not very
meaningful. For example, in assessment of the severity of pain due
to osteoarthritis, it would be more meaningful to ask what the patient
is unable to do as a result of the pain than ask the patient to rate the
severity of pain on a scale From 1-10.
Selection of site and study respondents
The site of data collection will be determined by access and
availability but the site should fit the study and not the other way
around. A random sample could be used but is not necessary, as
statistical representation is not a requirement. The study respondents
may be selected because they will be able to provide the needed
information or live in circumstances relevant to the phenomenon
being studied. This is known as purposive or theoretical sampling.
Sometimes the qualitative researcher may be compelled to use a
convenience sample, where selection of study subjects is based on
availability.

Study instruments
The researcher is the instrument in data collection. The ones that are
commonly used in medical research will be described - observation,
interviews, focus groups and narratives.

The researcher as an observer

The observer becomes involved with the lives of the subjects, yet
retains some emotional detachment. The observer may only observe,
interact with the subjects or even become involved in the work of an
institution while observing. Observation should be recorded as
accurately as possible. Therefore, the observer should take down
notes. Key words could be written and sentences completed soon
after. Since collection of data has to be in the subject's natural
setting, the observer should get permission from the head of the
institution and be aware of the ethical and legal responsibilities in
that setting.

Interviews
The researcher would have to make an appointment to meet the
subjects, give them sufficient information as to the reasons for the
study and get their permission to be interviewed. Location and
timing of the interview should be arranged to suit the convenience of
the subject. The researcher should create an open atmosphere and
have good communication skills.

Interviews have to be recorded on audio tape for which permission

from the interviewee should be obtained. Since an audio recorder
may inhibit some subjects, it should be placed as unobtrusively as
possible. Recording ensures that no information is missed and that
there is less room for misinterpretation. The subject should be
offered a transcript of the interview to verify whether what was said
has been interpreted correctly.

There are three main types of interviews - in depth, semi-structured

or structured.

In depth interviews
In depth interviews are unstructured which implies that a person is
interviewed on his or her views or feelings about a subject by the
researcher who conducts the interview with an open mind, without
having any preconceived questions to ask.

Semi structured
The researcher will have a standard set of questions but allows the
interviewee to feel free to elaborate on feelings about the topic being
explored. The researcher should be flexible and allow expression of
individual opinions to emerge.

Structured interviews usually consist of administering a structured

questionnaire by trained interviewers.

Self administered questionnaires could also be used.

Questionnaires should have some open ended questions to allow free

expression.

Focus groups
A focus group is where a group of 6-10 people sit together with a
facilitator / researcher and discuss a topic. The participants are
chosen purposively so that they are a relatively homogenous group
to ensure a free flow of discussion. Focus groups should preferably
take place in the natural setting of the subjects. The researcher
should identify a set of potential questions relevant to the research
idea which needs exploration. A research assistant should take down
notes. At the end of the discussion, the note taker will transcribe the
notes and audio tapes and the transcript will be used for data
analysis.

The facilitator should know the rules of how to conduct a group

session. The facilitator or researcher should begin the discussion
with general issues and later on move to more specific issues. A few
probing questions could basked to clarify any statements or
responses by the group. The facilitator will encourage spontaneous
expression of views and feelings and ensure a free flow of
discussion.

The researcher also decides on the number of sub-groups, how many

sessions - two per sub-group and for how long - One to two hours.
Depending on the study and circumstances, a focus group may be
limited to 45 minutes to one hour.

Focus groups could be used for the following :-

 As an idea generation tool - ideas on how a particular health
service (eg. Immunization service) could be improved
 To complement a qualitative study, to add the why and the how
to the how many.
 As a primary data collection method. Useful for studying issues
which are of a sensitive nature such as sexual behaviours, wife
abuse, abortion etc

Narratives
A narrative may be an autobiographical account of an illness
experience. For example a doctor who has suffered from cancer and
undergone surgery, radiotherapy and chemotherapy could give an
account of his experience which will give doctors an insight of what
such an illness means to the patient. A narrative may be obtained
from a caregiver about the last stages of a terminally ill patient.

Ethical issues
Informed consent from the subjects is necessary. Identities of all
respondents should remain anonymous and some form of coding
used for identification. Codes for identification will be known only
to the researcher and not made publicly known. Interviewees should
be assured of confidentiality. Permission should be sought from the
Heads of Institutions.

Limitations of qualitative research are small sample size, absence

of random sampling, inability to generalize and chance of bias being
introduced into the interpretations is high.
Management and Analysis of data in qualitative research

Data analysis should take place as soon as possible after data

collection.

The researcher will have a load of information in the form of field

notes, files, audio tapes, CDs etc.

The audiotapes of interviews or focus groups have to be transcribed

verbatim in detail. This is time consuming, a one hour interview
taking 6-7 hours to transcribe. Care must be exercised when
translating from the interviewee's or group's language to the
language of the researcher.

Next the researcher has to read the entire transcript in detail to

identify bits and pieces of information with a common meaning in
order to put them into categories. These may be phrases, incidents or
behaviours of the subjects.

Categories are given a code number and similar categories are

combined into themes. The term grounded theory outlines the
inductive process of identifying categories and themes as they
emerge from the data. Coding by an independent researcher would
ensure inter-coder reliability also referred to as multiple coding.
Coded excerpts of what individuals have said could be selected for
the final report.

All respondents may not adhere to a particular code and a single

incident or behaviour will be found which is important in behavioral
research as long as it is reported as a single finding. An outlier
though a problem in quantitative studies, are important in qualitative
research, because a deviant case may bring into focus the real
problem. This approach is acceptable because qualitative
researchers do not attempt or pretend to generalize.

Can numbers be used in qualitative research? The number of

interviews and focus groups, demographic characteristics of the
individuals, representativeness of focus groups, refusal rates and
frequency of codes and categories could be recorded.

Management of qualitative data analysis requires a system for coding

and retrieval of chunks of text and for organizing them into codes
and themes. The old fashioned way is to have two copies of the hard
data and cut and paste from one copy manually. With computers and
word processing packages, cutting and pasting from transcribed
interviews is easier.

Computer Assisted/Aided Qualitative Data Analysis Software

(CAQDAS) have been available since 1984, but they became
popular in qualitative analysis of data in the 1990s. These are code
and retrieve programs which could search and display coded parts of
the text. Some can list frequencies and connection between codes. A
considerable range of programmes are available to choose from but
some are only able to handle text while others can manage audio,
images and video. Examples of software programs are the
Ethnograph, NVivo, ATLAS.ti, Maxqda to mention a few.
Advantages and disadvantages exist for use of CAQDAS as opposed
to manual analysis of data which is time consuming. While
CAQDAS tools are helpful in reducing the time required to assist
with transcription analysis, coding, content analysis and grounded
theory methodology, according to some researchers, analysis and
particularly interpretation of data is more reliable when handled
manually. It must be remembered that software packages do not take
over data analysis from the researcher but merely help to manage the
data enabling the researcher to conceptualise and interpret the data.
So using the two together seems to be what is recommended at the
present time.

Threats to trustworthiness in qualitative research

Qualitative research is often criticized as it seems to lack reliability
and validity. In qualitative research the word used for validity and
reliability is rigour and trustworthiness. Any researcher seeks the
truth whether quantitative or qualitative. A trustworthy study is one
that represents as closely as possible the experiences of the
respondents, is convincing and has the power to change practice.
Certain threats exists to trustworthiness of qualitative research.
Methods have been devised to overcome these threats an to gain
credibility in scientific circles.

The threats are reactivity, researcher bias and respondent bias.

Reactivity refers to the potential distorting effects of the researcher
being present in the field which may interfere with the natural setting
and the behaviours that are being observed. Researcher bias could
arise when selecting whom to interview or when leading questions
are asked to get the required answers or during interpretation of data.
Respondent bias is obvious such as the respondent not telling the
truth or saying what the researcher expects to hear. This could
happen even in a quantitative study.

Strategies to overcome these threats and add rigour and

trustworthiness to a qualitative study

Prolonged engagement - The researcher stays a long time in the field

and becomes accepted as part of the setting. This reduces reactivity
bias and respondent bias.

Member checking or respondent validation - The researcher checks

with the respondent, whether the researcher's interpretation of the
respondent's views are correct. This guards against researcher bias.

Negative case analysis - the researcher challenges his or her findings

and understanding of the problem by deliberately looking for
evidence to challenge that understanding. This is like using the null
hypothesis in quantitative research. In both these we test our theories
by searching for falsifying evidence to refute them. If nothing is
found, research conclusions are more convincing. If negative cases
emerge it is not necessary to entirely discard the finding but it should
be mentioned and not suppressed.

Triangulation is where multiple perspectives about a phenomenon

are sought. This means doing multiple investigations, more than one
observer or many data sources.

Leaving an audit trail - This means documenting every stage of data

collection including raw data, transcripts, data analysis and the
strategies used to ensure trustworthiness. This would make the study
reproducible by another researcher to verify the findings. Auditablity
of the qualitative research is easier if one uses CAQDAS
programmes.

In conclusion qualitative methods of inquiry in medical research

could be used in combination with a quantitative method to enrich
the depth, scope and breadth of the research. Use of qualitative
research alone is useful in studying psychosocial problems, issues of
a sensitive and personal nature and medical problems where human
behaviour plays an important role.