Healthcare Delivery & Family Medicine

Healthcare Delivery Model

• Primary care does not require a referral.
• Patients in primary care include GPs, dentists, opticians, and community nurses.
• Secondary care includes ER, various specialties, physiotherapy, and dietitians; a referral is not needed for ER.
• Tertiary care requires a referral from secondary care and involves national/regional specialized care.
• Quaternary care is for very highly specialized care and involves rare, extremely complicated conditions.

Family Medicine Overview

• Family medicine is not simply general practice; it involves gatekeeping for cost-effective care.
• It requires a 3-year board program.
• It is the first point of contact for patients.
• Family medicine addresses acute and chronic illnesses and health maintenance through screening and immunization.
• Family medicine includes a wide range of patients, including all ages, males, and females
• Doctors can subspecialise.
• It is typically office-based without inpatient services.
• Other duties include managerial and research tasks.

Family Medicine vs. Other Specialists

• Family medicine doctors exclude serious diseases.
• Specialists confirm serious diseases.
• Family doctors tolerate uncertainty by waiting and seeing but investigate if necessary.
• Specialists reduce uncertainty through investigation until diagnosis.

Family Medicine (General Practice) Characteristics

• It emphasizes a personal, long-term, and patient-centered relationship.
• It focuses on the biopsychosocial model, considering factors like depression or blindness of a diabetic patient.
• It takes a holistic approach, offering complete care for all ages and both male and female patients, covering acute, chronic, and preventive aspects.
• It is efficient by being cost-effective, opting for "wait & see" approaches, and choosing the least expensive options.
• It is integrated, coordinating between different health services to reduce risks and expenses.

Family Medicine at KFS&RC

• It includes FM clinics that serve various types of patients.
• It consists of urgent care clinics and procedure clinics.
• Polyclinics cater to various patient types.
• Paediatric polyclinics are part of the family medicine services.

Course Objectives

• Understanding the role and definition of family medicine in patient care.
• Gain insights on common acute and chronic illnesses management like T2DM, HTN, DLP with ASCVD risk assessment.
• Learn to manage dizziness, chest pain, headache, UTI, musculoskeletal issues, care for the elderly.
• Address women’s health issues, including contraception, antenatal care, health maintenance & screening.
• Enhancing skills is a key learning outcome.
• Improve focused history taking, communication, prescribing and presentation capabilities to provide patient-centred care.
• Refining skills in physical examination.
• Refreshing knowledge about audit basics, research principles, and medical ethics.

Ground Rules

• Students should read the student manual 2022-2023.
• Signing in is not allowed if more than 10 minutes late.
• Persistent lateness will be investigated and may affect the completion of the ambulatory rotation.
• Leaving early is not permitted, even for exams or study.
• Honesty is expected, especially regarding attendance and emergency leave.
• Respect doctors, nurses, patients, and staff; issues should be reported.
• Coffee consumption in the clinic should be approved by the consultant and not be done in front of patients.
• Mobile phone use in the clinic/lecture should be limited to medical, chatting, or emergency purposes.
• Leaving the clinic/lecture for prayers, eating, buying coffee, or using the bathroom requires permission.
• Enthusiasm and active participation in patient care, discussions, and feedback seeking are encouraged; aim for at least one history and physical examination per clinic visit and have a better chance in the UCC.

Tutorials: Case Presentation

• Two student groups will present in week 2 and week 3, respectively.
• Two students will collaborate on each presentation to share the work and related discussions.
• Students will take the patient's history and perform their physical exam.
• Students also summarise diagnostic and management guidelines.
• The case presentation and summarised guidelines will make up the mark out of 100.

Tutorial Presentations

• Common presentations that may come up include diarrhea and vomiting (D&V), constipation, abdominal pain, SOB, cough, chest pain, palpitation, dizziness, headache, musculoskeletal symptoms, and lethargy.
• Chronic diseases follow ups for illnesses like asthma, COPD, heart failure, IHD, IBS, Crohn's, cerebrovascular disease etc.
• Health maintenance visits come up as well.

Tutorial Presentation Structure

• Part One includes patient psychosocial and medical history, presenting symptoms, physical examination, differential diagnosis, required investigations and a suggested management plan.
• Part Two is the summarisation of the latest guidelines relevant to the case.
• Part Three requires both students to engage other students to initiate discussion, and to answer any questions.

Exams

• The exam format includes MCQs and SAQs (Structured Assay Questions).
• The OSCE (Objective Structured Clinical Examination) will have 3 stations of 8 minutes each.
• The following stations involve conducting a history and physical examination with a management plan, breaking bad news, explaining a the diagnosis, explaining test results.
• Newer topics may include dealing with ethical dilemmas and prescribing skills.

Final Student Assessment:

• Attendance will be checked.
• The level of positive behaviour.
• Enthusiasm will be checked.
• Skill level will affect your score.
• Exam results will be calculated.

The Consultation Process

• Begin the history with "How can I help you today?".
• Get details on the presenting problem, such as dizziness, chronic disease symptoms, like known T2DM, if tests were done and what results came from them.
• Next review relevant Red Flags, ICEE, psychosocial factors like work, home, mood, smoking/alcohol/drugs, and lifestyle.
• Review PMH, drug, and allergy history.
• Conduct a focused physical examination.
• Explain the differential diagnosis (D/DD) in understandable language.
• Involve the patient in care by agreeing a plan in which you discuss the options and explain what you believe is the best choice for them.
• Discuss tests (lab, radiology, endoscopy), recommend pharmacological and non-pharmacological methods.
• Discuss a referral for a specialist, physiotherapy, psychotherapy etc, and include a health maintenance plan with vaccines, cancer screenings and how it involves lifestyle.
• Next set up a Follow-up and Safety plan: what are you going to do?
• Summarise clearly at the end of the consultation and ask if there’s any remaining questions.

Types of Consultations

• Symptom (Problem)-centred consultation: (e.g. Anemia).
• Disease-centred consultation: (e.g. Anemia caused by bowel cancer).
• Doctor-centred consultation: Anemia bowel cancer- arrange surgery.
• Patient-centred consultation: (e.g. above+ no surgery).

Patient-Centred Consultation Structure

• Effective methods of establishing rapport, effective questioning, active listening, clear explanations, and shared decision making.
• Recommending what's best will empower your patients.

Establish Rapport

• You must actively seek to establish a positive connection with the patient and shake their hand if appropriate.
• Introduce yourself and your position.
• Be welcoming.
• Ask the patient their preferred name.
• Break the ice by asking general questions such as weather or family.
• Ask for the patient's permission to take history, discuss results, and perform a physical exam, etc.
• Smile, empathise, and maintain eye contact.

Active Listening

• Have a dialogue, not a monologue.
• Listen with your eyes by maintaining eye contact and nodding.
• Pay attention verbal and non-verbal cues.
• Empathetic towards people's worries or problems.

Clear Explanation

• Explain test results, your assessment, and the plan.
• Employ medical jargon that best suits the patient's understanding.
• Speak slowly and clearly, avoiding rushing or sounding anxious.
• Chunk and check in a complicated situation.
• Get the patient to teach back to you to tell you what they understand.
• Use leaflets.

Shared Decision Making

• Decision-making must be negotiated with the patient.
• Present avaliable options, the best ones, and patient preferences to consider goals.
• Share your recommendations with patients, discussing benefits, risks, and involvement of investigations

Patient Behaviour and Prescriber Recommendations

• Compiliance means the patient follows the doctor's orders under pressure
• Adherance means the patient follows doctor's intstuctions willingly.
• Concordance means shared decision making taking into account patients conditions and preferences.
• Consider alternative compliance aid options.