Brief summary of family medicine and it’s application case in Indonesia.

Family medicine emphasizes responsibility for total health care-from the first contact and
initial assessment through the ongoing care of chronic problems. Prevention and early
recognition of disease are essential features of the discipline.

Coordination and integration of all necessary health services with the least amount of
fragmentation and the skills to manage most medical problems allow family physicians to
provide cost-effective health care.

The family physician provides continuing, comprehensive care in a personalized manner

to patients of all ages and to their families, regardless of the presence of disease or the
nature of the presenting complaint. Family physicians accept responsibility for managing
an individual's total health needs while maintaining an intimate, confidential relationship
with the patient.

History of Family medicine

The scientific/ biomedical model led to greater understanding of the pathophysiologic

basis of disease and the development of tools to help combat its influence. Sub
specialization of medical care facilitated the application of all the new information. We
now have practitioners who focus on the pieces and a society that appreciates their
abilities to fix problems.

Unfortunately this approach does not work well for chronic disease that involves more
than just a single part. In fact, all body organs are interconnected so that only repairing a
part without addressing the underlying causes for its failure provides only temporary
relief and a false sense of security.

Our modern medical system often caused frightening and dehumanizing experiences,
Too often the patient lost or forgotten in the process of diagnosis and treatment.
As a reaction in Europe and north America has born a new medical specialization
“family Medicine” which emphasized not only biomedical aspect but also psychological
and social aspect (biopsychosocial model).

Which have this characteristic:

1. A strong sense of responsibility for the total ongoing care of the individual and
the family during health, illness, and rehabilitation (5 level of prevention)
2. Compassion and empathy, with a sincere interest in the patient and the family
3. Enthusiasm for the undifferentiated medical problem and its resolution.
4. The ability to deal comfortably with multiple problems occurring
simultaneously in one patient (comprehensive).
5. The capacity to act as coordinator of all health resources needed in the care of a
patient
6. A desire to identify problems at the earliest possible stage (or to prevent disease
entirely)
 7. A strong wish to maintain maximal patient satisfaction, recognizing the need
for continuing patient rapport
8. An appreciation for the complex mix of physical, emotional, and social elements
in holistic and personalized patient care

Example of family medicine approach in Indonesia (palliative home care cases):

Our patient Mrs. Linda Sulistio d.o.b.: 20 Mei 1931 address jl permata hijau blok j1-41,
with the following
Medical history:
Capancreas painless jaundice April 2007plusstent
Stent block replace on 2/8/2007
DM
Pan Hypopititurism (tyroxine and hydrocortisone)
GERD complicated by Barrett’s esophagus
MALT Lymphoma chemo 1996 cure
Hp pylorus infection
Hypertension
Parkinsonism
Guillain barre 19932007 recurrent partial recover after IV gamma globulin
Penicillin allergy
Dyslipidemia
Totalhysterectomi and bil salpingo oophorectomy
Electrolyte disturbance
Present condition
On 18/08/07(one week after evacuation from Sing.) she developed cholangitis which is
further spontaneously healed; this patient was still under treatment of antibiotic
(ciproxin).
Further she developed ascites which could be caused by portal hypertension (venous
thromboses) dd tumoral process it self which is suggest by GI doctor in Sing. We don’t
do analyze of the cause of ascites, any way it is well responsive to diuretic treatment
which suggest portal hypertension. Her albumin concentration is within normal limits.
The families consult to Prof.L, he suggests billiar duct block can cause many problems;
this problem could be prevent if we place metal stent. We consult the GI doctor in
Singapore with the question: why they didn’t place the metal stent in the first place,
according to GI Sing the process of ercp of Miss Sulistio is difficult.
After discussing the benefit and the risk the family decided not to do the invasive
procedure (the obstruction parameter is improved, life expectancy of the patient short,
and there is a risk to do invasive procedure). Two week s later we perform usg which
show s no dilatation of intrahepatic duct, ascites and the measurement of pancreas
head is 4cm, all the lab parameters of obstruction of the billier duct also improved.
This patient developed SBP (spontan bacterial peritonitis) and prerenal renal failure on
16 Sep 2007 which cause hypotension (partly due to her hypapitituarism), fever and
uncontrollable diabetes, which is responsive to cefotaxim.
Presently she still has a couple of problems:
1. SBP which is responsive to cefotaxim
 2. Hyponatremia which is corrected with NACL 0.9%
3. Ascites which is treatted with lasix and aldactone.

If the patient general condition improved we will further the rehabilitation program so her
life quality will be improved.

On 30 September 2007
She get acute renal failure exacerbation caused by sepsis shock, her condition is
stabilized by antibiotic and corticoid substitution for her adrenal deficiency. After that,
she developed several complication ( gI tract bleeding, thrombocytopenia purpura and
hypotension caused by sepsis), the grieve process started many of the family member
crying.

We inform the family that her condition is critical and our focus is more to reduce her
suffer and not to give any reanimation again (DNR status more on palliative medicine).
Some family member asks our opinion to put her in ICU. Because of her irreversible
condition(CA Pancreas), our opinion is ICU is not the option our focus is more on
palliative medicine to improve her quality of life which is homecare better( less
opportunish infection, less over treatment and better environment for the dying
process) .

On 5 October 2007
We perform ascites punction to reduced her suffer (difficulty to breath and tightness
feeling on the stomach, her vital parameter stabilize with saturation O2, 96%. We inform
the family that her condition still critical and better to focus on her spiritual life. To
respect her wish, we stop taking blood sample laboratories for one week.

On 8 October 2007
She developed hypotension, caused by upper gi track bleeding. We inform to the family
that we still give the blood transfusion but incase the bleeding severe better to let the
patient go in peace and better to focus on spiritual think. 0n 16:00 she developed lung
congestion because of left heart failure, we gave high doses diuretic but she didn’t
response, to reduced her suffer we add morphine hcl which reduced her suffocation
feeling.
On 22: 00 she rest in peace.

In this case: we help the family member in grieve process to accept her pass away and
protect the patient for over treatment which can happen when she is hospitalized
(Reanimation, ICU, ventilator, inotrope, kidney dialysis, MRI, ercp, wallstent), WHICH
prolong her life but only INCREASED HER SUFFER.

The Family gets all the information regarding the progress of her diseases so they can
accept her pass away without any burden... (This patient was admitted in M.hospital
under prof.S. before but the family was very dissatisfied because of worse
communication. Then the patient was evacuated to Singapore for two weeks).
Most 7 problem that complaint by the patient(: 1. not enough time from the doctor, 2.
expensive, 3. the doctor to proud 4. not get enough information regarding the diseases 5.
not enough information regarding the expanses 6. waiting to long 7. no Tim work of
primary care doctor and the pessimist.) are good anticipated. We inform the family
member regarding the progress of the disease, the expense of expensive medicine, discuss
the advantage and disadvantage of all the technology that available for the patient and we
ask second opinion to her doctor in Singapore before proceed important medical decision
making for the patient best interest.

One of the reason why the patient want to get evacuated to Singapore before was
because of the democratic approach of SING doctor. The Sing doctor give time to
discuss with the patient regarding the progress of the diseases and also give the feedback
to the primary care doctor(resume report of the patient) But now they prefer us for the
home care because we can give better service quality, less expensive , more efficient and
comfort for the patient(palliative medicine).

The advantage of palliative home care are: 1. shorten the hospitalization(less

possibility of opportunish infection and over treatment,) 2. The patient stays more at
home in the middle of the family and friend, 3. More possibility to pass away at the
place where they want and belong.4. More satisfaction of medical services. 5...beter
treatment for acute and chronically symptomatic problem. 6. Less expensive
comparing with hospitalization.

In this case which base on the principal of Family medicine we can maintain maximal
patient satisfaction and be the best clinic in Indonesia.

Indonesia health care systems overvalue procedure in expense of medical compassion,

concern and patient trust which increase medical tourism in neighbor country.
Presently in Indonesia we have a disease cure system, not a health care system.

Family physician: the doctor from the womb to the tomb.