Patient-centered care

Nita Arisanti
Faculty of Medicine, UNPAD
Tujuan

• Menjelaskan prinsip kedokteran keluarga

• Menjelaskan pelayanan kedokteran keluarga
• Menjelaskan konsep pelayanan yang berpusat pada
pasien dan berfokus pada keluarga
Prinsip Kedokteran Keluarga
 WHAT? Dokter Layanan Primer

Kedokteran Kesehatan
Keluarga Masyarakat Kedokteran
80% Komunitas

Dokter Layanan Primer

adalah dokter yang mendapatkan pendidikan lanjutan setara
spesialis yang secara konsisten melaksanakan prinsip-
prinsip Ilmu Kedokteran Keluarga ditunjang Kedokteran
Komunitas dan Kesehatan Masyarakat serta mampu
Dokter
memimpin serta menyelenggarakan pelayanan kesehatan Layanan
tingkat pertama atau primer yang berkualitas Primer
Naskah akademik Kelompok Kerja Percepatan Pengembangan Pendidikan Dokter Layanan Primer, 2014
Why Should I See a Family
Doctor...?
Ilmu Kedokteran Keluarga (Family Medicine)
(WONCA-WHO, 2002; 2013)

Family medicine
is a component of primary Biomedical-
care and is defined as a clinical
specialty of medicine
concerned with providing science
comprehensive care to
individuals and families and
integrating biomedical,
behavioural and social
sciences. Family
Medicine Social
Behavior Sciences:
Sciences: . Public Health,
Psychiatry, Community
Psychology Medicine
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 Family Doctor/ General
Practitioner
• Family Doctor (Wonca-WHO, 2002; Wonca-WHO, 2013):
♦ is a physician who is a specialist trained to provide
health care services for all individuals regardless of
age, sex or type of health problems;
♦ provides primary and continuing care for entire
families within their communities; addresses physical,
pyschological, and social problems;
♦ coordinates comprehensive health care services with
other specialists as needed; may also be known as
family physician (FP) or general practitioner (GP)
depending on location of practice

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Primary Health Care

WHO (2008) suggested that it should be:

1. General (patients have not been pre-selected according to their
medical condition);
2. Continuous (the same physician cares for same patient over time);
3. Comprehensive (covers all conditions);
4. Coordinated and Collaborative (doctors are linked to other sources
of care and are the case-managers for that patient);
5. Family-oriented (ideally, patient and other family members treated
by same health care team); and,
6. Community-oriented (responds to health needs of the community).

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• Family Medicine/
General Practice:
• An academic &
scientific discipline,
with its own
educational content,
research, evidence
base and clinical
activity, and a
clinical specialty
orientated to
primary care [with
12 characteristics,
clustered into 6 core
competencies)
(Euract, 2011)

Definition of Family Medicine/General

Practice (Euract, 2011)
 The Principles
DEDICATED TO
THE PERSON
MANAGER OF UNDERSTAND THE
RESOURCES CONTEXT OF ILLNESS

SUBJECTIVE ASPECTS ALL CONTACT WITH

OF MEDICINE PATIENTS AN
(SENSITIVITY TO OPPORTUNITY FOR
FEELINGS, EMOTIONAL
FAMILY PREVENTION & HEALTH
ETC) PHYSICIAN EDUCATION
HOME VISITS (SEES THE PRACTICE AS A
PATIENTS AT HOME) POPULATION AT RISK

LIVE IN COMMUNITY/ A DOES COMMUNITY

PART OF THE COMPLEX OF NETWORKING
FAMILY RELATIONSHIP
THE PRINCIPLES ARE:

1. Family physicians are committed to the person rather

than to a particular body of knowledge, group of
diseases or special techniques. It is not limited by the
type of health problem and has no defined end point.

2. The family physician seeks to understand the context

of illness.

3. The family physician sees every contact with his

patients as an opportunity for prevention or health
education.
THE PRINCIPLES ARE (CONT’D)

4. The family physician views his or her practice as a

“ population at risk “

5. The family physician sees himself or herself as part

of a communitywide network of supportive and
health care agencies

6. Ideally, family physicians should share the same

habitat as their patients
THE PRINCIPLES ARE (CONT’D)

7. The family physician sees patients in their

homes.

8. The family physician attaches importance to the

subjective aspect of medicine. Family
medicine should be a self-reflective practice

9. The family physician is a manager of resources

Scope of Practice
Scope of Practice

• Personal care
• Primary care
• Continuing care
• Comprehensive care
Personal care
● Care delivered w/ a close rapport between the doctor &
the patient, through:
- Humanistic approach: humane medical care
- Good doctor-patient relationship
- Effective communication skills (study results*)
● Family Doctors do not just treat patients; they care for
people:
- understanding the patient as a person
- respecting the person as individual; and
- showing compassion for his/her discomfort

“It is much more important to know what sort of patient has

a disease than what sort of disease a patient has…” (Sir
William Osler, 1904)
(Goh, 2007; Goh et al, 2004; Rakel, 2002; 2011)
Primary Care
● First contact care for undifferentiated health problems: might be an
urgent or chronic problem; predominantly acute & preventive care
● Accessibility is essential: financially affordable & geographically
accessible
● The availability of the physician: is therapeutic & has a
comforting & calming influence
● As the patient’s first contact, the Family Doctor (FD) must be
knowledgeable of a broad array of diseases and have the skills
and judgment for medical evaluation
(Goh, 2007; Lipsky & King, 2006; Goh et al, 2004; Boelen et al, 2002; Rakel, 2002)

Slide Oryzati
Continuing Care
● Primarily person-centered rather than disease-centered →
based on a long-standing personal relationship between
the patient & the doctor over substantial periods of their
lives & not limited to one particular episode of an illness
● Nourishes a trusting long-term relationship between
patient & doctor → improves patient adherence to
treatment recommendation
● Successful continuous relationships includes:
a. Assessing disease risk
b. Screening for illness
c. Promoting health to prevent disease & disability
(Goh, 2007; Lipsky & King, 2006; Rakel, 2002; Boelen et al, 2002)

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Comprehensive Care

● Comprehensiveness has 3 meanings:

¤ addressing the physical, psychological & social
problems
¤ covers health promotion, preventive, curative,
rehabilitative and palliative care
¤ caring for all age groups
(‘from cradle to grave’; ‘from womb to tomb’)
● Family practice:
¤ dealing with the interface between illness & disease
¤ integrating the humanistic & ethical aspects of the
doctor-patient relationship with clinical decision-
making
(Goh, 2007; Goh et al, 2004; Rakel, 2002; Boelen et al, 2002; Kidd, 2013)

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 Thomas Kuehlein, Quaternary prevention: a task of the general practitioner, http://www.primary-care.ch/docs/primarycare/archiv/fr/2010/2010-18/2010-18-368_
ELPS_engl.pdf
Patient-centered and family focused care
Patient-centered, family-focused &
community-oriented care

● Patient-centered care:
• Good doctor-patient relationship is important to help the patient
improve his health status & well-being
• Exploring both the disease & the illness experience
• Four dimensions of patient’s illness experience:
ideas, feelings, effects on function & expectations
(Leopando, 2003; Goh, 2007, Goh et al, 2004, Steward et al, 2000, Boelen et al, 2002)

Slide Oryzati
 Exploring both the Understanding Finding
Disease & illness the whole Common
experience person ground
Physical, history, lab
Disease CONTEXT PROBLEMS
Patient PERSON
Presents GOALS Mutual
Illness
cues Decision
Illness Disease
Ideas, feelings, effect ROLES
on functions,
expectations

Enhancing Incorporating
Patient-doctor Prevention and Being realistic
relationship Health promotion

The Patient-Centered Clinical Method

Patient-centered, family-focused &
community-oriented care

● Family-focused:
• Family as the unit of care
• The patients’ health problems should be seen in the
context of their family circumstances, their social &
cultural networks and the circumstances in which they
live & work.
(Leopando, 2003; Goh, 2007, Goh et al, 2004, Steward et al, 2000, Boelen et al, 2002)
Slide Oryzati
Patient-centered, family-focused &
community-oriented care

● Community-oriented:
• The patients’ health problems should be seen in the
context of their life in the local community
• FD should be aware of the health needs of the
population living in this community
(Leopando, 2003; Goh, 2007, Goh et al, 2004, Steward et al, 2000, Boelen et al, 2002)

Slide Oryzati
 Pelayanan berpusat pada Pelayanan berfokus pada
individu keluarga
Integrasi antara masalah medis dan biopsikososial
Anamnesis Keluhan utama, riwayat Riwayat keluarga,
dan penyakit sekarang, riwayat determinan kesehatan,
pemeriksaan penyakit dahulu, riwayat sumber daya yang dimiliki,
fisik pengobatan, riwayat sosial dan isu caregiver
perilaku
Ide, persepsi, ketakutan,
kekhawatiran tentang penyakit

The Pemeriksaan
penunjang
fisik dan

concept
Analisis, Diagnosis banding Penilaian keluarga
termasuk Fase penyakit Dampak penyakit
diagnosis Dampak penyakit Kepatuhan/ compliance
Kepatuhan/ compliance
Rencana Untuk diagnostik Pemeliharaan kesehatan
penatalaksan Untuk terapi individu dan keluarga
aan Suportif Reassurance
Alternative
Follow up
Rujukan
Case
Comprehensive Care Questions
A 46-year-old Chinese man has been seen
for the last 10 years on and off at a
Government Polyclinic. There had been 1. What are this patient's
no complaint of epigastric pain before. In problems?
November 2005, he was seen for
epigastric pain lasting for a week. He was
initially treated with Mist Mag trisilicate 1. If you were his doctor, what
and cimetidine 200mg bd. He returned
two weeks later and said he felt better. A would you like to explore
further 4 weeks of cimetidine 400mg bd with him to help you have a
was given. He improved but was seen better understanding of him
again in March 2016 because the pain had and his disease?
recurred. He said he took some NSAIDs
from a GP for backache.
1. What is the broad scope of
He works as an electroplater in the aircraft action that you can take in
industry. He says he feels rather stressed
at work. He requests for a week's MC. caring for this patient?
References
1. Mc Whinney. A textbook of Family Medicine. Second Edition, Oxford New
York, 1997. pp 3 -28, 229-57, 381-87,411-19
2. Lee Gan, Azwar.A, Wonodirekso. Family Medicine Practice. Singapore, 2004.
3. Azrul Azwar. Dokter Keluarga. Direktorat Jenderal Bina Kesmas Departemen
Kesehatan RI. Jakarta, 2002. pp 1-15, 23-31
4. WONCA EUROPE. The European Definition of General Practice/ Family
Medicine. 2011
5. Leopando ZE, et al. Textbook of Family Medicine. Principles, Concepts,
Practice and Context. Volume 1. 2014
6. Nita Arisanti. Prinsip dan Konsep Kedokteran Keluarga. Modul Pendekatan
Biopsikososial yang berpusat pada pasien dan berfokus pada pasien dalam
penatalaksanaan masalah kesehatan pasien. Electronic Continuing Professional
Development. 2016