1. DEPT. OF PUBLIC HEALTH & PREVENTIVE MEDICINE FACULTY OF MEDICINE-PADJADJARAN UNIVERSITY 2013 THE ORIGINS OF FAMILY MEDICINE

2. SPECIFIC LEARNING OBJECTIVES Understand family medicine as a discipline (C1) Recognize the changes in paradigm in medicine (C1) Understand the growth and background of family medicine (C1) Describe the definition and scope of family medicine (C2) Understand the place of Family Medicine and integrating Family Medicine’s efforts in Health Care (C1)

3. DEFINITION OF PUBLIC HEALTH The science and the art of: (1) preventing disease, (2) prolonging life, and (3) promoting physical health and efficiency through organized community efforts for: (a) the sanitation of the environment, (b) the control of community infections, (c) the education of the individual in principles of personal hygiene, (d) the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, (e) the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health so organizing these benefits as to enable every citizen to realize his birthright of health and longevity (Winslow, 1920)

4. PREVENTIVE MEDICINE: a Specialized field of medical practice composed of distinct disciplines which utilize skills focusing on the health of defined populations in order to promote and maintain health and well-being and prevent disease, disability, and premature death (Last, 1987)

5. SOCIAL MEDICINE : A term used to emphasize the importance of man’s environment to his health. In this sense, environment includes the human society in which man lives and the multitude of complex interpersonal relationships that so profoundly affect his health (Leavell & Clark, 1958)

6. COMMUNITY MEDICINE that branch of medical science which is concerned with the health needs and interventions of population groups of known size and composition. That is, it is concerned with health of what is commonly known as defined population groups (Lathem, 1979)

7. DEFINITION OF FAMILY MEDICINE Family Medicine (FM) is 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 biologic, clinical, and behavioral sciences. The scope of FM encompasses all ages, both sexes, each organ system and every disease entity (American Academy of Family Physicians/AAFP, 1993)

8. FAMILY MEDICINE AS A DISCIPLINE (LEE GAN, AZWAR AND WONODIREKSO, 2004) The other names: general practice or primary care medicine Family medicine is a discipline concerned with the provision of personal, primary, comprehensive and continuing health care of the individual in relation to his family, community and his environment The term is preferred to emphasize the family as a sociological unit providing support to the individual as well as to reiterate the importance of the family in the cause and effect of health and disease in the individual.

9. SCIENTIFIC APPROACHES IN PUBLIC HEALTH Epidemiology, Biostatistics,Biological & physical sciences,Social sciences, Demographic science, Surveillance, Intervention and Evaluation PREVENTIVE MEDICINE SOCIAL MEDICINE FAMILY/PRIMARY CARE MEDICINE COMMUNITY MEDICINE

10. FAMILY DOCTOR/ PHYSICIAN (WONCA, 1991) The physician who is primarily responsible for providing comprehensive health care to every individual seeking medical care, and arranging for other health personnel to provide services when necessary. The FP functions as a generalist who accepts everyone seeking care whereas other health providers limit access to their services on the basis of age, sex, and/ or diagnosis.

11. FAMILY DOCTOR (LEE GAN, AZWAR AND WONODIREKSO, 2004) is a qualified medical practitioner who provides personal, primary, comprehensive and continuing health care of the individual in relation to his family, community and his environment. he may attend to his patients in his clinic, in their homes or sometimes in the hospital. in treating his patients, must take into consideration the whole person, their psyche as well as their body systems and must not treat just the signs and symptoms. in providing comprehensive and continuing care, he will need to interact with his medical colleagues. in promoting health, he will not only treat therapeutically but also educate and counsel his patients

12. PRIMARY CARE (AAFP, 1993) Primary Care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for ill persons or those with undiagnosed sign, symptom, or health concern not limited by problem origin (biologic, behavioral or social), organ system or gender. Primary Care includes, in addition to diagnosis and treatment of acute and chronic illnesses, health promotion, disease prevention, health maintenance, counseling and patient education, in a variety of health care settings such as office, inpatient, critical care, long term care, home care and day care. Primary Care is performed and managed by a personal physicians, using health professionals for consultation or referral as appropriate.

13. PRIMARY CARE ( AMERICAN BOARD OF FAMILY MEDICINE, 2004) PC is a form of delivery of medical care that encompasses the following functions: 1.It’s first-contact care, serving as a point of entry for the patient into health care system 2.It includes continuity by virtue of caring for patients over a period of time in sickness and in health 3.It’s comprehensive care 4.It serves a coordinative function for all the health care needs of the patient. 5.It assumes continuing responsibility for individual patient follow-up and community health problem. 6.It is a highly personalized type of care

14. FAMILY MEDICINE HOW DID FAMILY MEDICINE BEGIN ? WHAT ARE THE REASON WHY FAMILY MEDICINE HAS INCREASED ?

15. FAMILY MEDICINE 2. NEW DISCIPLINE 3. HAS EVOLVED FROM G.P 1. PARADIGM CHANGES IN MEDICINE Old paradigm new paradigm HOW DID FAMILY MEDICINE BEGIN ?

16. 1. WHAT IS THE OLD PARADIGM IN MEDICINE ?  IS ALSO KNOWN AS THE BIOMEDICAL MODEL  A DISEASE CAN BE VIEWED INDEPENDENTLY FROM THE PERSON WHO IS SUFFERING FROM IT AND FROM HIS SOCIAL CONTEXT  MENTAL AND PHYSICAL DISEASE CAN BE CONSIDERED SEPARATELY  EACH DISEASE HAS A SPECIFIC CAUSAL AGENT  THE PHYSICIAN’S MAIN TASK IS TO REMOVE THE CAUSE AND RELIEVING THE SYMPTOMS  THE CLINICAL METHOD AND THE CLINICIAN USUALLY BECOMES AS AN OBSERVER AND THE PATIENT BECOMES AS A PASSIVE RECIPIENT

17. THE ANOMALIES ENCOUNTERED BY THE OLD PARADIGM 1.THE DISEASE ANOMALY: A LARGE PROPORTION OF ILLNESSES CANNOT BE DIAGNOSED TO A SPECIFIC DISEASE CATEGORY 2.THE SPECIFIC ETIOLOGY ANOMALY: NOT ALL THE POPULATION WILL GET SICK FROM THE SAME AGENT 3.THE MIND/ BODY ANOMALY: MIND AND BODY WERE SEPARATED 4.THE PLACEBO EFFECT AS A MIND/ BODY ANOMALY 5.PHYSIOLOGICAL PATHWAYS 6.NEW KNOWLEDGE OF THE IMMUNE SYSTEM

18. 2. THE NEW PARADIGM IN MEDICINE  DISEASE IS NOT SEPARATED CONCEPTUALLY FROM THE PERSON, NOR THE PERSON FROM ENVIRONMENT  ALL ILLNESSES AFFECT THE PATIENT AT MULTILEVELS  THE TASK OF THE PHYSICIAN IS TO UNDERSTAND THE NATURE OF THE ILLNESS ON ALL ITS LEVELS  ALL LIVING SYSTEMS ARE OPEN SYSTEMS, IN THAT EXCHANGE BOTH ENERGY AND INFORMATION ACROSS THE SYSTEM INVOLVES INTERFACES OR BOUNDARIES  SYSTEM HIERARCHY IN THE HUMAN BODY ARE MOLECULES, CELLS, TISSUES, ORGAN SYSTEMS, NEUROENDOCRINE IMMUNE SYSTEMS, PERSON, FAMILY, COMMUNITY, CULTURE AND SOCIETY.

19. 3. FAMILY MEDICINE HAS EVOLVED FROM G.P G.P F.M A. CHANGES IN MORTALITY AND MORBIDITY B. GROWTH OF SPECIALIZATION C. THE AGE OF G.P AND SPECIALIZATION D. NEW DEVELOPMENTS IN THE BEHAVIORAL SCIENCES E. CHANGING ROLE OF THE HOSPITAL F. THE AGE OF MANAGED CARE DEMAND ON A NEW TYPE OF PHYSICIAN

20. A. CHANGES IN MORTALITY AND MORBIDITY DEVELOPED COUNTRY  THE SUCCESSFUL CONTROL OF THE MAJOR INFECTIOUS DISEASE  SEVERE ACUTE ILLNESSES CHRONIC DISEASE  THE REDUCED MORTALITY INCREASED THE PROPORTION OF ELDERLY  PUBLIC HEALTH TO PRIVATE HEALTH DEVELOPING COUNTRY  DOUBLE BURDEN OF DISEASE  COMMUNICABLE AND NONCOMMUNICABLE DISEASES (Behavioural causes e.x. life style, smoking, abused etc) CLEAN WATER, A BALANCED DIET AND GOOD HOUSING ARE STILL MAJOR DETERMINANTS OF HEALTH

21. B. THE GROWTH OF SPECIALIZATION HEALERS PROFESSION GENERAL PRACTITIONER SPECIALIZATION (MEDICAL, SURGICAL)  PUBLIC NEEDS  SOCIAL PRESSURES

22. GEYMAN (1971), FAMILY DOCTOR/ PHYSICIAN IS: 1.GENERAL PRACTITIONER 2.A SPECIALIST ( GENERAL PRACTITIONER + 3 YEARS) USA 3.GENERAL PRACTITIONER OR SPECIALIST WHO PROVIDE HEALTH SERVICES WITH THE BASIC PRINCIPLES OF FAMILY MEDICINE/ FAMILY MEDICINE APPROACH INDONESIA 4.DEVELOPED GENERAL PRACTITIONER

23. D. NEW DEVELOPMENTS IN THE BEHAVIORAL SCIENCES INSIGHTS INTUITIVELY ORGANIZED APPROACH TO PROBLEMS BEHAVIORAL SCIENCES HAS DIRECTED TO THE PROCESS BY WHICH PEOPLE SEEK MEDICAL CARE, A CRUCIAL FOR ALL PRIMARY PHYSICIANS IT’S MAKING US MORE AWARE OF THE IMPORTANCE OF OUR BEHAVIOUR IN DETERMINING OF THE QUALITY OF CARE IT HAS INCREASED OUR INSIGHTS INTO THE DOCTOR – PATIENT, FAMILY RELATIONSHIP AND BEHAVIORAL ASPECTS OF ILLNESS

24. NEW DEVELOPMENTS IN THE BEHAVIORAL SCIENCES (CONT’D)  IT HAS MADE US THINK ABOUT SOME OF THE FUNDAMENTAL ASPECTS OF MEDICINE ( CONCEPTS OF HEALTH, DISEASE AND ILLNESS, THE ROLE OF PHYSICIAN AND THE ETHIC OF MEDICINE)  IT HAS BROUGHT TO OUR ATTENTION THE POOL OF ILLNESS THAT NEVER REACHES THE MEDICAL PROFESSION  IT HAS INCREASED OUR KNOWLEDGE OF BEHAVIORAL AND SOCIAL ECONOMIC FACTORS INVOLVED IN THE CAUSATION OF DISEASE

25. 50 % 20 % 10 % Global burden of disease, Murray & Lopez, WHO, 1996

26. E. THE CHANGING ROLE OF THE HOSPITAL THE COST OF INPATIENT CARE HAS BECOME SO PROHIBITIVE THAT CRITERIA FOR ADMISSION TO THE HOSPITALS so strict FOR THOSE WHO NEED CARE FOR A VARIETY OF PROBLEMS OVER A LONG PERIOD OF TIME, THE HOSPITAL IS A MUCH LESS SATISFACTORY FORM OF CARE FRAGMENTATION OF CARE FREQUENT CHANGES OF PERSONNEL THE ANTITHESIS OF INTEGRATED PERSONAL MEDICINE THE HOSPITAL PROVIDES SPECIALIZED SUPPORT WHEN IT IS NEEDED WHAT ABOUT PRE AND POST HOSPITAL CARE ? Who provides them ?

27. F. MANAGED CARE AND THE AGE OF INTEGRATION PRIMARY LEVEL: FAMILY PHYSICIAN / GATE KEEPER SECONDARY LEVEL TERTIARY LEVEL THE OTHER HEALTH PROFESSIONALS AND COMMUNITY SUPPORT SERVICES ECONOMIC FORCES MANAGED CARE (HMO- US)

28. WHAT TYPE OF PHYSICIAN IS DEMANDED ? Charles Boelen : Family doctor is NOT A SOLUTION but the bridge between hospital care and public health. He is able to help save costs through being a five stars doctor DECISION MAKER CARE and CURE PROVIDER COMMUNICATORCOMMUNITY LEADER MANAGER OF HEALTH CARE RESOURCES DECISION MAKER

29. THE FIRST THREE OF CENTRAL VALUES, ARE ATTITUDES THAT WE WOULD WANT TO INFECT ALL DOCTORS WITH: PATIENTS CENTRED CARE AND ATTENTION TO THE DOCTOR-PATIENT RELATIONSHIP. HOLISTIC APPROACH TO THE PATIENT AND HIS PROBLEMS THAT RECOGNIZES CONTRIBUTIONS TO ILL - HEALTH AND WELL- BEING COME FROM NOT ONLY PHYSICAL DISEASE BUT EQUALLY IF NOT MORE FROM SOCIAL ECONOMY AND PSYCHOLOGICAL DIMENSIONS IN THE PATIENT AS WELL AS FROM THE FAMILY AND HIS COMMUNITY. EMPHASIS ON PREVENTIVE MEDICINE BECAUSE THIS HAS GREATER LONG TERM IMPACT ON HEALTH STATUS THAN CURATIVE MEDICINE.

30. THE NEXT THREE CENTRAL VALUES DEFINE THE FAMILY DOCTOR’S WORK THE FAMILY DOCTOR LOOKS AFTER HEALTH PROBLEMS THAT MAY BE INITIALLY UNCLEAR IN TERMS OF SERIOUSNESS THE FAMILY DOCTOR LOOKS AFTER PEOPLE ACROSS THE WHOLE SPECTRUM OF AGE GROUP ~ HE IS A SPECIALIST IN BREADTH THE FAMILY DOCTOR IS WILLING TO LOOK AFTER THE PATIENT NOT ONLY IN THE CONSULTING ROOM BUT ALSO IN THE HOME AND OTHER SETTINGS AS WELL

31. THE PLACE OF FAMILY MEDICINE IN HEALTH CARE: DIVISION OF LABOR FIRST CONTACT CARE (GENERAL PRACTITIONER/ FAMILY MEDICINE SERVICE/ PUSKESMAS) LOOKING AFTER PATIENTS THAT COULD BE MANAGED OUTSIDE THE HOSPITAL

32. Definition of Primary Care: The setting within a health care system, usually in the patient’s own community in which the first contact with the health professional occurs The European Definition of General Practitioners/Family Medicine, WONCA Europe, 2002

33. THE PLACE OF FAMILY MEDICINE IN HEALTH CARE: WORKING TOWARDS UNITY FOR HEALTH INTEGRATION OF CLINICAL ACTIVITIES ( TO INTEGRATE WITH HOSPITAL BASED DISCIPLINES: PAEDIATRICS, INTERNAL MEDICINE, GERIATRICS etc) INTEGRATION WITH PUBLIC HEALTH INTEGRATION WITH SOCIAL AND ECONOMIC DEVELOPMENT OF THE COUNTRY STAND ALONE ~ DANGER HAS THE ROLE OF INTEGRATING IN THE MIND OF EVERY DOCTOR THE BALANCE BETWEEN SPECIALIZATION AND GENERALIST APPROACH IN THE PATIENT CARE

34. INTEGRATING FAMILY MEDICINE’S EFFORTS IN HEALTH CARE DELIVERY 1.GOOD PREVENTIVE CARE 2.GOOD ACUTE CARE 3.GOOD CHRONIC DISEASE CARE MANAGEMENT 4.GOOD STEP-DOWN CARE ~ IS VERY IMPORTANT WITH THE RISING COST OF ACUTE HOSPITAL CARE AND THE INCREASING NUMBERS OF THE ELDERLY WHO TAKE A LONGER TIME TO RECOVER FROM MEDICAL ILLNESSES. 5. GOOD ELDERLY CARE 6. GOOD DOMICILIARY CARE 7. GOOD PALLIATIVE CARE +

35. FAMILY MEDICINE IN INDONESIA  THE CONCEPTS FIRSTLY REVEALED IN THE NATIONAL CONFERENCE OF INDONESIAN MEDICAL ASSOCIATION IN 1980  INDONESIA IS ONE OF WORLD ORGANIZATION OF NATIONAL COLLEGE, ACADEMIC & ACADEMIC ASSOCIATION OF G.P/F.P (WONCA) MEMBERS, REPRESENTED BY THE INDONESIAN COLLEGE OF FAMILY PHYSICIANS (KDKI)  NOW: THE INDONESIAN ASSOCIATION OF FAMILY MEDICINE (PDKI)  INDONESIAN NEEDS FAMILY MEDICINE ORIENTED PRIMARY CARE DOCTORS TO BE EFFECTIVE GATE KEEPERS IN THE HEALTH CARE DELIVERY SYSTEM

36. REFERENCES 1.Mc Whinney. A textbook of Family Medicine. Third Edition, Oxford New York, 2009. pp 5 -12. 2.Lee Gan, Azwar.A, Wonodirekso. Family Medicine Practice. Singapore, 2004. Section 3 chapter 1 pp 24-5, 42-8 3.Azrul Azwar. Dokter Keluarga. Direktorat Jenderal Bina Kesmas Departemen Kesehatan RI. Jakarta, 2002. pp 1-15. NEXT SESSION: PRINCIPLES AND PHILOSOPHICAL FOUNDATIONS OF FM