Medical Social Integration from a Family Doctors Perspective

Medical Social Integration from a Family Doctor’s Perspective

• What are the differences between caring for a sick elder and a sick young adult? • Why family doctors are in the best position to deliver community elderly care? • Case example to demonstrate why medical and social integration is necessary for the delivery of optimal community elderly care. • What are the obstacles of providing elderly cares by family doctors?

What are the differences between caring for a sick elder and a sick young adult? • Elderly patients commonly have multiple • • problems, including medical, mental and social conditions. Chronic illnesses also are more common in the old population. The elders have decreased reserve capability. The presentation of a sick elder is commonly atypical.

What are the differences between caring for a sick elder and a sick young adult? • When people get old, changes in body composition make older people more vulnerable to adverse drug reactions. • The intellectual decline, together with multiple physical deficits will cause problems in communication. • Caring for frail elders requires both multidimensional and multidisciplinary management.

What are the differences between caring for a sick elder and a sick young adult? • The elderly population is heterogeneous. That is • to say, for the same age group of elders, their health status is not uniform and there is tremendous variation. As people age they become more individual and differentiated. There is increasing variability with age - among individual and among levels of functioning from day to day.

What are the differences between caring for a sick elder and a sick young adult? • Because of this variability, chronological age per se has lost its meaning as a marker of personal capacity. • As a general rule while managing sick elders, care becomes more important than cure and function more important than diagnosis.

What are the differences between caring for a sick elder and a sick young adult?

What are the differences between caring for a sick elder and a sick young adult? • In the care of elderly patients, family members • provide the majority of care necessary to keep their frail elders in the community. Therefore, a visit to the doctor’s office often includes the family caregiver accompanying the elderly person. Thus the doctor-patient encounter, which is commonly dyadic becomes triadic.

What are the differences between caring for a sick elder and a sick young adult? • The role of the caregiver during these visits may not always be predictable: it may be facilitative , supportive or neutral. It can also be antagonistic, such as the coopting of an agenda to meet the caregiver’s own needs. Therefore, doctors need to have good communication skill in triadic encounter. • Furthermore, in the care of their elderly patients, doctors may find themselves not only assisting caregivers in problem-solving and referral to community resources but also assessing the caregiver’s health and coping skills.

What are the differences between caring for a sick elder and a sick young adult? • Caring for elders is stressful; the caregiver is encompassed with the physical, social, psychological, and financial toll of providing care. The caregivers become the “hidden victims”. • Recent finding has shown that family caregiving is an independent risk factor for mortality among elderly spousal caregivers.

What are the differences between caring for a sick elder and a sick young adult? • Informal caregivers have a higher level of • depression, more likely to experience physical pain, and more likely to experience financial stress. Failure by doctors to recognize the burden on informal caregivers may result in long term adverse outcome on this group that may outweigh the benefits of managing people with disability and chronic illness in the community.

What are the differences between caring for a sick elder and a sick young adult? • Caring for the caregiver, thereby reducing • caregiver burden and helping with carerecipient problems, could result in great benefit for the patient, informal caregiver and for the larger community. Doctors who look after the family and know the family function well, they are most suitable in the healthcare systems to assist both the frail elderly and their family informal caregivers.

Why family doctors are in the best position to deliver community elderly care? • Are readily available and affordable. • Are accustomed to provide holistic and family care. • The family doctor seeks to understand the context of the illness. Many illnesses cannot be fully understood unless they are seen in their personal , family and social context. When a patient is admitted to the hospital, much of the context of the illness is removed or obscured. Therefore, it is not unreasonable for hospitalized elders request their family doctors to pay visits to them.

Why family doctors are in the best position to deliver community elderly care? • Family doctors provide continuity of care • and there is evidence that continuity of care is associated with patient satisfaction, decreased hospitalizations and emergency department visits and improved receipt of preventive services. The family doctor views his or her practice as a “population at risk. ” Always think patients in terms of both as single and population groups. This concept is important for the delivery of anticipatory care.

Why family doctors are in the best position to deliver community elderly care? • They have earned trust from the • • family long before seeing the patient. They have owned comprehensive knowledge of their patients. They practice patient-centered communication in such a way that it is correlated with the patient’s and caregiver’s perception of finding common ground.

Why family doctors are in the best position to deliver community elderly care? • They practice learnt communication skills • • (triadic encounter, poor historians). They are used to deliver coordinated care. They are frontline doctors therefore they are in the best position to offer preventive care and functional geriatric assessment. They are keen to establish good patientdoctor relationship since it has always been their first priority. They advocate the practice of evidencebased medicine

Case example to demonstrate the importance of medical and social integration • Mrs. Lau a 72 -year-old, type II diabetic. • Caregiver for her husband who is also one of my patients. • Mr. Lau, in addition to coronary artery disease, has hypertension, osteoarthritis, cataract, gout, anxiety, and had a stroke three years ago.

Case example to demonstrate the importance of medical and social integration • She complained to me during one of the regular follow ups that she was getting tired easily, losing weight, and lack interest in many things despite good blood glucose level control. • I routinely enquired for caregiver stress, she suddenly bursted into tears and frankly admitted that she was disturbed by her husband’s unusual behaviour.

Case example to demonstrate the importance of medical and social integration • For the last few months, her husband had become very unreasonable, stubborn, irritable, and sometimes acting strangely. She began to has negative thoughts such as she was not wanted any more, she was not good enough for him, and they could no longer tolerate one another. Since she did not think that it was a medical problem, therefore she did not come for help. She became helpless and was trying hard to find the solution herself. She had decided that if the problem could not be solved, she would have to send him to an OAH.

The analysis • The longstanding doctor-patient relationship and knowledge of the medical and social background of the family helped me to spot the following problems. • Mrs. Lau’s family, in addition to the underlying medical problems, there were undetected new medical problems and social problems. • In this case, the new medical problems had emerged as a complication of her husband’s underlying medical diseases.

The analysis • The new medical problems were: Dementia and depression which are common in elders with multiple chronic diseases, especially those with a history of stroke. • The social problems were: Caregiver stress. Imminent family breakdown. Mr. Lau would have to be transferred to OAH against his will.

The management • I explained to her that the situation was not the same as what she thought instead it was the consequence of the new medical problems. I provided information about the management of the current situation. It was very effective in mitigating her emotional sufferings. I further offered non-drug, and drug treatment to Mr. Lau. Eventually the problem was solved. Additionally, Mrs. Lau was also screened for hidden psychological problem.

The management • In order to solve the social problems that came with the medical problem, namely dementia, I had also discussed with the family about referral to social services where supports for caregivers and dementia patients are being provided.

The importance of medical and social integration • Had I not enquired about the social situation (caregiver stress), I would have missed Mr. Lau’s medical problem. • On the other hand, the social problems would not have been solved unless the medical problem was detected and managed.

The importance of medical and social integration • Doctors usually pay attention to medical problem and ignore social problem, but in the management of community elderly patients, holistic management is always necessary. Very often, in order to solve the elder’s problem, the doctor has to integrate the medical and social situations so as to find the solution to help the elderly patient and family.

What are the obstacles of providing geriatric cares by family doctors? • The private family doctor do not have sufficient • • government support. By and large, continuity of care is not viewed important in the care of elderly patients both by the public and government. The one way referral system preposterously operating in Hong Kong , makes it extremely difficult for family doctor to manage and follow sick elders.

What are the obstacles of providing geriatric cares by family doctors? • The family doctors do not have interdisciplinary team support which is often required for the care of elderly patients. • There are few if any, private and public health care services integration.

What are the obstacles of providing geriatric cares by family doctors? • • • Do not have adequate geriatric medicine training. Fortunately, there are courses like PDCG and PDCPM in Hong Kong that can help to supplement the family doctors’ knowledge. Ageism exists even among medical professionals. Comments such as old people are all similar and there is little value of doing anything for them are often heard. Communication problem resulting from cognitive impairment is one of the many reasons why doctors are reluctant to see elderly patients.

What are the obstacles of providing geriatric cares by family doctors? • Family doctor’s role in OAH is made in such a • • • way that it is replaceable and expandable. He is not sharing the leadership role in the management. Provision of preventive services by family doctor is difficult because of financial constraint. Time constraint. Reimbursement and remuneration.

References • 1. The dementia caregiver-a primary care • • approach. Stuti Dang et al, South Med J. 2008 Dec; 101(12): 1246 -51. 2. Family medicine attributes related to satisfaction, health and costs, Mireia Sans. Corrales et al. , Fam Pract. 2006 Jun; 23(3): 308 -16. 3. Physician Perspectives on the elderly patient-family caregiver-physician encounter. Mark J. Yaffe et al. , IMAJ 2002; 4: 785 -789 4. The physician’s role in nursing home care: an overview. M E Williams, Geriatrics 1990 Jan; 45(1): 47 -9. 5. A textbook of family medicine, 2 nd edition, Ian R Mc. Whinney.