Family Medicine encompasses several medical specialties and a family physician must train to be a “jack of all” medical disciplines, caring for pediatric as well as elderly patients. Residency training in family medicine includes rotations in internal medicine, pediatrics, obstetrics and gynecology, psychiatry, and geriatrics. In addition, knowledge of interpersonal skills, compassion, and professionalism are essential to developing long-term relationships with the patients and their families.
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Definition

In the increasingly fragmented world of health care, one thing remains constant: Family physicians are dedicated to treating the whole person. Family medicine´s cornerstone is an ongoing, personal patient-physician relationship focusing on integrated care.

American Academy of Family Physicians

Personal Holistic Integrated Efficient
  • Good communication principles and empathy
  • Embraces biopsychosocial model
  • Put patient in context of relationships
  • Complete patient care
  • Focus on preventive care
  • Coodination between health services
  • Emphasis on patient values and practices
  • Less resource-intensive; driven by history and physical
  • Ownership of the whole patient

Accurate and Efficient Patient Histories

Getting started — introduction

☑ “Good morning! I´m Dr. …”

☑ “How would you like to be addressed?”

☑ 80 % of patients prefer to shake hands—more important for minority patients

☑ “What bring you to the clinic/ emergency room today?”

Note: Let the patient diagnose her/himself!
 Follow patient´s leads Use “continuers”  Ask directly 
  •  Patient: “It hurts more when I eat. It all started when I ate some strange food.”
  • Physician: “Tell me about that.”
  •  “I see.”
  • “Tell me more.”
  • “Go on.”
  • “Mmm hmmm.”
  •  Ask the patient directly what they think they have.

The first step for a physician is obtaining a history of the patient’s complaints and related symptoms. Accuracy and efficiency in obtaining a history are the keys to avoid inadvertent medical mishaps and incorrect diagnosis.

A detailed history of the chief complaint includes origin, duration, and progress of the complaint, along with associated/aggravating and relieving factors. After this, the physician should inquire about personal history (habits, addictions), family history, medication history, past history of surgeries/ illnesses and allergies to medications.

If the patient has pain, the using a pain scale, he/she should be asked to quantify the pain and inquire about factors which aggravate and relieve the pain. It is also important to obtain a detailed history of associated symptoms, their onset, duration, intensity and factors which influence them. Sexual history and use of contraception also help to narrow the diagnosis in many cases.

Getting all the facts—do´s and don´ts

Do´s

Ask specific close-ended questions Go back to open-ended questions
  • “Does the pain radiate?”
  • “Have you tried anything (medications, exercise, ANYTHING) to alleviate the pain?”
  • Physician: “Do you have other symptoms when the pain comes?”
  • Patient: “No.”
  • Physician: “Specifically, do you feel nauseous?”
  • Physician: “Have you had fever?”

Don´ts

  • Don’t inquire into more than 2 symptoms with 1 question.
  • Don´t bias the answer: “You don´t have fever, do you?” vs. “Have you had fever?”

Keys for a busy practice

  1. A general review of systems doesn´t improve outcomes.
  2. General physical exam doesn´t improve outcomes but increases health care costs
  3. Average number of patient issues in a primary care visit: 7
  4. Open-ended questions gain more information than close-ended questions.
  5. Open-ended questions don´t add greater length to the visit.

Transitioning to a Diagnosis & Plan

Once an accurate and complete history has been obtained, the physician can perform a focused as well as related organ system exam. A complete physical examination is also warranted but can be deferred for later in emergency cases, if time is a constraint. Formulate one or more differential diagnosis and reasons to include or exclude them.

Next, the transition to a plan of management which is important to explain to the patient what has been deduced from the history and physical exam and what the patient should expect from the investigations and treatment. It is very important to discuss the options for care and involve the patient in the decision-making process.

The role of a family physician is to provide preventive care as well as treat the most common ailments and this can be done through better communication with the patients and their families. The family physician may have to care for patients from diverse backgrounds and needs to address the patient’s concerns without bias.

Caring for Diverse Populations and Cultural Humility

Definitions Race

A vague unscientific term for a group of genetically related people who share certain physical characteristics.

Definition Ethnicity

Ethnicity means a social group characterized by a distinctive social and cultural tradition maintained from generation to generation, a common history and origin, and a sense of identification with the group.

Members have distinct features in their way of life, shared experiences, and often a common genetic heritage; these features may be reflected in their experience of health and disease.

Definition Culture

The shared values, beliefs, and practices of a particular group of people, which are transmitted from one generation to the next and are identified as patterns that guide the thinking and action of the group members are called culture.

Caring for Diverse Populations and Cultural Humility

The population in the United States is becoming increasingly diverse with patients speaking in several different languages.  Delivering medical care to the population can be a challenge and providing it effectively requires cultural competence and cultural humility. Cultural competence includes laws, rules, policies, practices, and attitudes to improve the interactions within the health care setting or by medical professionals to serve effectively in cross-cultural situations.  Examples of cultural competence within health care are:

  • Medicaid which requires medical providers to provide culturally and linguistically appropriate services and
  • Medicare which requires linguistically accessible services to be provided

Cultural humility incorporates life-long self-evaluation and self-critique to maintain patient-physician dynamics and ensure that the relationships are mutually beneficial instead of being paternalistic. In practice, it means that individuals should learn to respect patients and partners from diverse groups and communities. Appreciation, acceptance, flexibility, and openness are the core values of cultural humility.

Transgender health

  • Prevalence estimated: 1 % among birth-assigned males & females (approximately 25 million people worldwide)

Cardiovascular Disease and Determinants of Health

Cardiovascular disease is a general term used to describe conditions like myocardial infarction, angina or stroke caused as a result of atherosclerotic narrowing of the blood vessels. Several risk factors have been identified for the development of cardiovascular diseases such as smoking, obesity, high blood pressure, diabetes, sedentary lifestyle, family history of heart disease and a diet high in cholesterol, fat, and sugar.

Three determinants have been studied extensively with regards to cardiovascular health – education, income, and occupation. For example, lower levels of education are associated with a higher prevalence of cardiovascular risk factors and a higher incidence of cardiovascular events and mortality. Studies show that there was a 50 % reduction in mortality due to cardiovascular causes with an increase in the family income. The relationship between cardiovascular health and occupation is, however, not so crystal clear as poor health can result in unemployment and vice versa.

Key Tool: LEARN

L Listen with empathy and respect

E Explain your perspective

A Acknowledge differences and similarities

R Recommended treatment

N Negotiate a plan of care

Implicit (Unconscious) Bias

We may harbor feelings and attitudes subconsciously about people around us based on their race, age, appearance or ethnicity. Implicit bias refers to these attitudes which influence our actions and decisions unconsciously.

These usually develop over a lifetime due to our direct and indirect environmental influences such as through our interactions with people, media, and news. Some of the characteristics of implicit bias are:

  • They are pervasive and are possessed by everyone irrespective of gender, race or country of origin.
  • Usually, implicit bias favors our own in-group although we may hold a bias against our in-group too.
  • These biases are malleable as our brain can unlearn them through debasing training.
  • They are not always aligned with our explicit beliefs
  • Explicit and implicit biases are mentally distinct but still related and can reinforce each other.

e.g. a white physician who implicitly associates African American patients as being uncooperative is unlikely to refer an African American patient with acute coronary symptoms for percutaneous intervention.

Form of rapid cognition that finds patterns based on small bits of information.
Ancient reflexive system Adaptive: danger detector
Refers to social stereotypes about certain groups of people that individuals form outside their own consciousness

Coordination of Care

In primary care practice, coordination of care is very important and involves organizing and sharing all the activities involved in patient care with everyone associated with the care of the patient. The goal is to ensure that the patient’s preferences are recorded and communicated to the right people at the appropriate time to deliver effective medical care safely. Well designed coordination of care improves outcomes for not only the patients but also for the providers and payers. The following are some of the examples of approaches involved in care coordination:

  • Health information
  • Teamwork
  • Managing care
  • Medical management
  • A medical home centered around the patient

Several resources are available for primary care practitioners to learn more about coordination of care such as:

Care Coordination Quality Measure for Primary Care (CCQM-PC)

Care Coordination Measures Atlas—June 2014 Update

Care Management: Implications for Medical Practice, Health Policy, and Health Services Research. Care Management Issue Brief

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