Anticipatory care

When meditating over a disease, I never think of finding a remedy for it, but, instead, a means of preventing it. Louis Pasteur 1884

If we take responsibility for preventive work only of proven value we shall have our hands full.

4 1Diseased, diagnosed & controlled 2Diagnosed, uncontrolled 3Undiagnosed or wrongly diagnosed disease 4Risk factors for disease 5Free of risk factors Diagnosed disease Undiagnosed or wrongly diagnosed disease Iceberg phenomenon ?

Does it work? USA: Mortality from stroke has decreased by 50% since 1972 – Early diagnosis and treatment of hypertension Mortality from cervix cancer decreased by 80% – Pap smear Neonatal screening: Decrease in mental retardation – Phenylketonuria screening – Congenital hypothyroidism 5 National Center for Health Statistics.

Health Promotion Includes all measures which promote good health and prevent or delay the onset of disease or their complications. The essential union of prevention with care and cure (RCGP,1981).

Health promotion WHO "the process of enabling people to increase control over and improve their health

Why in Family Practice ?

Frequent contact between patient and doctor over many years Responsibility for a defined population The contribution of PHC team The power of dr-pt relationship

Role of Clinician in Prevention:- Changes in the pattern of diseases and opportunities for prevention Limitation of high technology medicine Pressure on doctors to practice prevention

Aims : 1-Improve the quality of life. 2-Reduce the burden of premature disability. 3-Increase life expectancy.

Health Promotion : 1-Primary Prevention: Health education. Prophylaxis.

Action taken to prevent the occurrence of diseases e.g. health education, immunization, sanitation sterilization of surgical instruments, eradication as with mosquitoes to prevent malaria. * No disease or symptom but risk factor present

Primary Prevention: A. Health education: Aims to enlighten people by providing them with information factors which are known to cause disease. B. Prophylaxis: An active intervention in an attempt to protect the individual from developing a particular disease e.g.: vaccination.

Cont. 2-Secondary Prevention: Screening. Case finding. 3-Tertiary Prevention : systematic long term monitoring to prevent or minimize the impact of complication.

Secondary :- Early diagnosis and prompt treatment Disease present and diagnosable but no symptoms present ScreeningPlanned (pap smears, mammography) Opportunistic (check B.P. pt with sore throat) Difference between planned and opportunistic

Tertiary:- Management of established disease so as to minimize disability Disease diagnosed and symptom present e.g. Management of D.M. to reduce complication rehabilitation of stroke patient

What are primary care physicians doing? Health Care Health promotion Risk prevention Risk reduction Early diagnosis Complication reduction Preventive Medicine! Primary Prevention Secondary Prevention Tertiary Prevention

Secondary Prevention: A. Screening: Are systematic attempts to detect undeclared disease in a population of apparently healthy people.  Before mounting a screening initiative certain criteria must first be satisfied (Wilson, 1973).

PHE Evaluation of apparently healthy individuals in certain time periods, using a number of standard procedures such as counseling, physical examination, and laboratory investigations is called Periodic Health Examination.

The Criteria: 1- The condition (the disease) sought should be: Important. Recognizable at an early stage. Readily treatable.

Cont. PHE 2- The screening test used should be: Practical and safe. Acceptable to patients and non invasive. Highly sensitive and highly specific and easy to interpret. 3- Facilities for diagnosis and management should be readily available.

Cont. PHE 4- Treatment should be: Recognized Effective. 5- The cost of screening test should be balanced and screening should be a continuous process. 6- To agree on a policy on whom to treat.

Cont. PHE 8-The population screened : Sufficiently high disease prevalence. Accessibility 9-Compliance with subsequent diagnostic tests &necessary therapy.

Does it work? USA: Mortality from stroke has decreased by 50% since 1972 – Early diagnosis and treatment of hypertension Mortality from cervix cancer decreased by 80% Neonatal screening – Decrease in mental retardation Phenylketonuria screening Congenital hypothyroidism National Center for Health Statistics.

Rationale: Many young people die every year due to RTA > 90,000 die < 65year : <32,000 due to cancers. <25,000 due to IHD. Cessation of smoking <33% reduction in all cancers. <25% reduction In IHD. Treating & controlling hypertension reduce CVAs by 50%

Think of your daily life A50-year old woman applies to your office. She has no history of disease but afraid of having breast cancer. – Should you perform a breast exam? – Should you teach her breast self exam? – Should you order a mammography? How do you decide?

Rationale It’s an important disease for women – Worldwide new cases/year. (1/1000) – Ist female's cancer (Saudi cancer registry) It can be recognized early without symptoms – Mammography Curable – Surgery, Chemotherapy, Radiotherapy The value of treatment is far more than its adverse effects

Screening / PHE programs in Saudi Arabia Annual periodic health examination for all diabetic and hypertensive patients registered at PHC Cervical screening Breast cancer screening in some areas Pre-marital screening (genetic dis., infectious dis.) Well baby clinic 30

Costs of Screening Patients: anxiety false reassurance economic Doctors government

Obstacles to Prevention Discuss the obstacles to prevention from: patients doctors government

Overcoming Patient Obstacles Point out debits Point out benefits Anticipate and discuss difficulties Suggest coping strategies Simple advice and written information

Conclusion: Management decision must be related to one or more of the following objectives:  Prevention of an illness.  Prevention of disability in curable illness.  Prevention of further disability in chronic disease.  Prevention of relapse.  Prevention of death.

Principles of patient education Interest the recognition of the need patients are unlikely to listen to those things which are not to their interest Motivation

Principles of patient education Participation active learning Known to unknown knowledge is build up to enable patients to develop an in-depth insight into their own health problems

Principles of patient education Comprehension Making patient understand what you say Educational background Mental capacity Re inforcement repetition of the information in the same or during subsequent consultation

Principles of patient education Encourage the patient to participate in decision making and in accepting some degree of responsibility for his/her own management Record body weight glucocheck Monitoring temperature B.P

Principles of patient education Encourage feed back Involvement of others e.g. family members where appropriate Establish wheather the objectives have been met and the patient is happy with the outcome

Principles of patient education Provide take away information patient instruction leaflets resource contacts Arrange follow up Reinforcement of information preventive measures

Principles of patient education It is sometimes wrongly assumed that just by providing people with information, they will automatically be able to make healthy choices. Examples ??

Principles of patient education Fahad 55 years old blind recently diagnosed type 2 diabetes mellitus, come to the primary care clinic for follow up visit. How you will help fahad to understand and cope with diabetes?

Patient education model Establish the patient’s knowledge of the problem Describe the problem Establish the patient’s attitudes to the problem

Patient education model Correct any incorrect health beliefs Supplement the patient’s existing knowledge to a level appropriate to the needs of the patient and the doctor Facilitation by the use of special charts, diagrams, models.

Patient education model Explore other preventive opportunities Reinforce the information Develop a management plan immediate long term patient participation in decision making

Patient education model Learning by doing the right step towards positive action Good human relationship patients must accept you as a friend Leader patients learn best from the educator whom they respect and regard

conclusion Practicing the principles of patient education will facilitate the doctor relationship with patients and families and improve patient’s satisfaction, and outcome.