Family medicine is based on a series of central concepts developed by family doctors, general practitioners and generalist educators from all over the world, during the past 25 years. Among those who contributed to the discipline are names such as Michael Balint, Ian McWhinney, Gayle Stephens and others mentioned in this chapter. The concepts described in these pages are dynamic and continue to refine themselves in theory and practice . The most important thing is that they constitute the bases of the clinical approach of the family doctor towards the patient and the disease of it. This first chapter and, by the way, a lot of this book may be better understood when some of the terms are defined.
The specialty, discipline, and doctor who practice it
Family Medicine (Family Practice) *: The specialty is called Family Medicine. In many countries, general practical expression or general medicine is used and those who exercise them follow the basic principles of family medicine. In other places there is a clear distinction between general practice, which implies the lack of specialized training, and the practice of family medicine, which has an explicit emphasis on the principles described in this book. < / p >.
In the United States, the practice of family medicine was clearly developed from the practice of general medicine and in 1971 the American Academy of Medicine changed its name transforming the American Academy of Family Physicians.
.
The practice of family medicine was defined by the American Council of Family Medicine (ABFP) as follows: "...... is the medical specialty that cares about the care of the total health of the individual and the family . It is a specialty in amplitude that integrates clinical, biological and behavioral science. The scope of family medicine is not limited by age, sex, organ or system or morbid entity. "
Family Medicine (Family Medicine): It is scientific medicine that serves as a foundation of the Family Medicine specialty. It represents the body of accumulated knowledge related to the health, illness and health care of the individual in the context of the family.
In principle -solly two or three decades ago - the clinical content of family medicine consisted mostly of knowledge derived from other specialties. The first investigations in family medicine had the importance of integrating the
________________________
NT: In English, the expression "Family Practice" is used to name the specialty and "Family Medicine", to discipline. In the Spanish-speaking countries, it is called family medicine both at the specialty and discipline.
Family problems in health care and insist on new concepts such as family systems, family dynamics, family apgar and health care through the family life cycle. Later studies came to include more biomedical problems, especially those involving common topics in ambulatory care such as the & ldquo; Screening “ For colorectal cancer, pregnancy management and normal delivery, treatment of pharyngitis or sinusitis. Current research is responding to important questions to provide quality health care with limited resources, for example: What is the appropriate screening method for prostate cancer? And what is the most appropriate initial treatment for hypertensive patient?
Family medicine also includes the development of new areas of special competence - also called aggregate ratings. Family doctors have long been the main suppliers of attention to adolescents, athletes and the elderly; Some family doctors chose to strengthen these areas of work in their practices. The Table 1 List areas of special experience in family medicine.1
Table 1
Areas of special competence in Family Medicine
Health care in adolescents
Geriatric health care
Promotion of health and well-being
Occupational Medicine
Health care based on the population
Sport Medicine
Traveler Medicine
Family doctor: is the one that practices the specialty and uses the principles of family medicine.It is the doctor who provides continuous and comprehensive health care in the context of the family without limitations by age or gender of the patient or because of the type of problems that are biological, psychosocial or behavior, or any combination thereof.
Today's family doctors have a true general mentality;They value handle people's problems more than diagnosis and treatment treatment.They see themselves as "humanists, people oriented, and understanding." 2
Health and discomfort
Family doctors generally have a pro-active approach to health, which is defined as a positive welfare state and not merely the absence of disease or disability. The Connote definition an active search for the best physical and mental state possible, and includes elements of primary prevention and health promotion.
The state of discomfort has different components: the disease refers to a biological or psychophysiological disorder having symptoms and specific signs.3
The discomfort describes the experience of patient's disease and includes sociocultural problems as well as family beliefs about health and illness.
Health care is the process of improving health, returning to the person to the ideal state of optimal well-being. When the disease is present, the family doctor works to control the symptoms, eliminate the cause of the disease and prevent or minimize disability; Care is provided in the context of the patient's belief system, family dynamics and community culture. For the patient with back pain or epigastric pain, the family doctor makes a diagnosis, prescribes treatment, advises the patient about the appropriate adjustments in the activity or diet, and recommends ways to prevent recurrences - all considering the capacity of the Patient to understand and act according to the recommendations. When there is no disease, it is put on the accent on the increase in health -including diet and appropriate exercise, and avoiding behaviors and harmful substances.
Clinical method:
María L, she is a 32-year-old school teacher with a year of a year of recurring headaches. The pain is usually in the right Sien, appears once or twice a week, it lasts until she goes to sleep and usually calm down with the dream. The patient reports that she is "dragging some problems" with her mother, she has lost much of her enthusiasm for teaching and lately she has been waking up early in the morning.
One of the greatest contributions of family medicine to the body of knowledge has been the clinical care approach based on models. Family doctors, by generally serving many patients per day, learn to recognize patterns of signs and symptoms and compare them with disease models. The models are based on epidemiological probability and from there that the family doctor quickly recognizes that man in the middle age of life with epigastric distress is likely to have a dyspepsia and not a gastric cancer; In addition, it is likely that a vital stress is playing some role.
The Method of Family Medicine is different from the most aggressive deductive methods that have traditionally been used in medicine - approaches based on the collection of the maximum amount of information and then razon generally to the particular. This method uses much more time and resources than that of the practice of family medicine and in the end produces similar clinical results.4.5
The following are concepts of family medicine that form the basis of the clinical method based on models and in epidemiology.
Reason for consultation
The reason why The patient consults the doctor may be the key to understanding the disease.6 A common reason is to obtain pain relief or other symptoms; This reason is often self-evident in the case of an injury such as a knee torsion. In other circumstances, the patient is mainly concerned about the meaning of the symptom, such that if chest pain represents an indigestion or coronary disease. For the consultation to be successful, the doctor should address the problem in the context of why the patient came to see the doctor.
Sometimes, the complaint expressed (eg fatigue) is really an "admission card" to treat the underlying problem (eg sadness). Other reasons for the visit include: problems of life such as family stress or be over-cooked, administrative purposes such as the need to fill out a form, preventive care including visits for & ldquo; screening “ In health and the need to legitimate the behavior of the role of sick.
Although Mary seemed to request relief for his headaches, who had begun to interfere with his teacher's work, the family doctor wondered if the patient may also be requesting help to treat his family problems that included his mother , Carmen, who came to live with Maria and her husband Juan, about 18 months ago.
Meaning of the disease for the patient
Symptoms, physical signs and deterioration of a function should be all considered in the context of what it means for the patient. For a patient, a back pain can cause intoactivity intoactivity; For another it is a probability of avoiding going to work for a while. A minor discomfort can provide a convenient excuse to avoid a non-pleasant activity, and therefore for this patient "disease" has a positive meaning.
Maria was always proud of her's ability as a teacher, and headaches along with apparent depression were compromising her effectiveness at work. In her house the headaches of her allowed him to retire to her room and avoid unpleasant confrontations with Carmen, who had been openly critical of John, the work of her, her friends and her relationship with María .
Influence of the family about the disease
Family interactions can have a profound effect on health or disease. Does the patient come from a family in which health is valued, in which smoking is not tolerated and exercise is in high consideration? Does the family neglect health and practice risk behaviors? The family, in fact, seems to give importance to the disease with frequent complaints due to minor symptoms?
The way one deals with apparent diseases has its roots in the family and culture of the community. In an environment, the symptoms are ignored until the function deteriorates and the patient is literally forced to request medical care. In other families, the first sneeze or mucus needs a call to the doctor.
Family interactions profoundly influence health, especially, problems that may have psychophysiological components such as abdominal and pelvic pain, anxiety and depression, fatigue, and - in the case of the patient María -or torque.
In response to the open questions of the family doctor, Maria told him about the death of her father, the sadness of her mother and her's decision to invite her to live with her and John. The problems began quickly, when Carmen began to criticize the long hours of work of John and the habits of him to make a stop on the way to her house to take a drink with her friends. María found himself in the middle of a conflict that was growing.
Focused interrogation
The way in which the words are used in the medical interview has been called the "procedure" of the family doctor.7 Family doctors use for & ldquo; Screening “ Very broad-based questions to eliminate early in the interview, unlikely diagnoses and to concentrate on the most likely causes of the disease. Before a lot of medical doctors have identified patterns of patient signs and symptoms and have compared them with disease models found in the past. The non-common and unlikely diagnoses are not forgotten but, without compulsive evidence of their presence, they can generally be deferred for subsequent consideration if the patient does not respond to the initial treatment.
The symptoms of Mary were accommodated to two family patterns: migraine headache and depression. The neurological examination was normal what constituted a confirmatory and reinsurer element.
Appropriate intervention at the appropriate time
For any complaint there is, virtually , A therapeutic or diagnostic intervention available, which consumes time, is expensive and sometimes painful. But not all headache requires X-rays or each episode of constipation justifies a colonoscopy. One of the principles of family medicine is that longitudinal care is a powerful diagnostic tool and most of the diseases that are not resolved spontaneously, they will be revealled over time. Because the patient will return to the consultation for follow-up, the doctor is dispensed with the obligation to always do the definitive diagnosis on the first visit.
This cautious use of tests and treatments, benefits both the patient and society. Unnecessary evidence is avoided and cost-effective attention is provided. The emphasis on the appropriate and timely distribution of resources has made family physicians the most favored suppliers in those means where the efficient use of time, equipment and suppliers, is important, as happens in States United, in Management Organizations. *
Because the clinical findings in Mary were as typical of migraine and depression, no more examinations were needed. The doctor prescribed an analgesic and an antidepressant and asked her that her mother accompany her on the next visit.
Impact of the disease about the family
It is rare that a disease affects an isolated person. More often the disease comprises a whole family constellation. In an acute illness the patient is allowed to assume the "role of sick"; That is why he is dispensed with him, he may be in bed and other family members are expected to attend and show an adequate concern. However, it also considers that the role of sick consumes vital resources of the family: the energy used to provide care, the cost of medical care and the loss of income of the patient and perhaps from those who care for it. Maybe you should cancel plans to go out one night or go on vacation. A person's disease can spread to another, or it may result in discomfort or injury due to the role of caregiver.
Worse is still when there is a chronic or recurrent disease, such as a stroke or diabetes mellitus insulin dependent. Before a lot of the disease becomes a bit of all who coexist and family members assume the role of continuous caregivers. It often follows resentment and anger.
Family doctors recognize the impact of the disease over the family and believe that a symptom of dyspnea or anxiety expressed by the patient in the examination room, affects somehow affects others of the cohabitation.
In the next visit, María brought her mother Carmen from her. Both analyzed together as John was becoming angry and distant, whom he blamed Mary's headaches. They talked about how, although Mary was "the identified patient" because she was the one who had pain, the real problem was in family interactions. They agreed that it was unlikely that Mary's headaches will be resolved until the family conflict ceases. She had opened an important line of communication.
________________________
* NT: This type of organizations also exists in other countries
Continuous and understanding attention
By providing continuous care, the family doctor may be involved with the patient from before birth until after the death of it. Family doctors can provide care before conception and bring children into the world. They provide attention to their patients during childhood, childhood, adolescence, adulthood and ancientity. Comprehensive care includes the wide handling of all types of problems. The family doctor coordinates specialized attention by arranging any necessary consultation or derivation and maintaining the interest and commitment of it even when other doctors are providing services:
There is a great emphasis on preventive care. Family doctors are responsible for implementing screening in health and recommendations to prevent disease, performing tests such as Papanicolau examination and immunizations as well as antique vaccination. The anticipatory guide as advisors with respect to responsible sexual behavior are also part of the practice of family medicine. When the patient has a disease such as hypertension, the family doctor performs preventive attention by controlling blood pressure and reducing the risk of complications.
Comprehensive care includes the management of complex interactions of behavior, communication and disease, among several family members as seen with Maria the mother of her and her husband.
In her last visit, Maria reported that her headaches had improved and that she was taking more pleasure in her work. She continued to use antidepressant medication. She, Carmen and Juan had begun to talk about how to avoid criticism and angry answers and how they could live together peacefully.
The clinical method in practice
If a disease is presented in an organ of a person who lives in isolation, and has no psychosocial or cultural context, it can be cured by a specific medication for that disease prescribed by a trained doctor to treat that organ. In fact, this has been the tacit presumption of medicine until recently. Fortunately, family medicine was developed in the last part of the 20th century to combat the fragmentation of superspecialized medicine and to practice and teach the clinical method of family medicine. If the medical interview is the "procedure" of the family doctor then the clinical method of family medicine must surely be the "instrument" - an instrument that family doctors use and teach daily in medical clinics and schools around the world.
