PERAN DOKTER KELUARGA DALAM PENATALAKSANAAN DIABETES MELITUS

Prof.DR. Didik Tamtomo,dr PAK, MM, MKK

Definition

Family Medicine is defined as the medical speciality which provides continuing and comprehensive health care for individuals and family. (American Academy of Family Physicians)

• General Practitioner/ Family Doctor • Doctors who have undergone postgraduate training in general practice

• General Practice/ Family Medicine • An Academic and scientific discipline , with its own educational content, research, evidence base clinical activity, and a clinical speciality oriented to primary care.

• Family Physician is defined as an egde of a spear in a health care service

Service quality?

The Characteristics of the Discipline a) Point of first medical contact dealing with all health problems regarding of age, sex, or any other characteristic of the person b) Efficient use of health care resources through coordinating care, working withother professionals in the primary care setting, and by managing the interface with other specialities talking an advocacy role for the patients when needed

c) Person-centered approach, oriented to the individual his/her family, and their community d) Has a unique consultation process, which establish a relationship over time, through the effective communication betweeen doctor and patient e) Promotes health and well being both by appropriate and effective intervention

f)

Has a specific decision-making process determined by the illness in the community

g) Manages simultaneously both acute and chronic health problems of individual patient

h) Manages illness which presents in an undefferented way at an early stage in its development, which may require urgent intervention

i)

Continuity/continuing of care as determined by the needs of the patient

Contuining Care ( 3 C )

• Control • Compliance • Complication

1.CONTROL

Comunication: Defined as process by which people share ideas, experience, knowledge and feelings . Usually spoken or written words, pictures or symbols. body language, gestures, looks, facial expressions .

• Communication theory – Communication is a learned skill which is based on 3 pillars 1 Accuracy 2 Efficiency 3 Supportiveness

Between doctor and patient

– Patient-centered’ approach (Mutuality) • Facilitate their patients to participate • Use of ‘open’ questions e.g. ‘tell me about your pain’, ‘how do you feel? & ‘what do you think is the cause of the problem?’ • Active listening skills, requires more time (participative style)

Patient’s role in mutual relationship

• Patients need to define their problems in an open and full manner. • The patient’s right to seek care elsewhere when demands are not satisfactorily met.

Doctor’s role in mutual relationship

• Physicians need to work with patient to articulate the problem and refine the request • Physician’s right to withdraw services formally from a patient if he or she feels it is impossible to satisfy the patient’s demand

• Patients can fully understand what problem they are coping with through physicians’ help • Physicians can entirely know patient’s value • Decisions can easily be made from a mutual and collaborative relationship

The importance of a good PATIENT DOCTOR RELATIONSHIP lies in the : – Confidence – Trust

– Knowledge – Shared knowledge about diseases and how they are related

Consultation Style

It’s serious isn’t it doctor?

The doctor’s consulting style

Paternalistic - doctor is the expert and patient expected to cooperate Tightly controlled interviewing style aimed at reaching an organic diagnosis.

Paternalism

The traditional D-P relationship Doctor Takes on role of “parent” Patient submissive Shift towards Mutuality

The Paternalistic Approach

“If I’ve told you once I told you 1,000 times, stop smoking!!”

Patient Centred consultation style •

Less authoritarian - encourages patient to their own feelings and concerns • Open questioning, interested in psychosocial aspect of illness

Types of D-P Relationship Patient Control

Physician Control LOW

HIGH

LOW

Default

Paternalism

HIGH

Consumerism

Mutuality

Roter,D and Hall, J.2006

Patient controlled consultation

“You’re

paid to do what I tell you!!”

Asymmetry Information

Health Promotion and Prevention • Level of Prevention – Primary : true prevention • immunizations, teaching value of exercise

– Secondary :directed at diagnosis and intervention • screening papsmear, vission, bearst

– Tertiary : directed at rehabilitaion with permanent and irreversible diases • Cadiac rehabilitation, diet for new diabetes

MEDICAL RECORD

Referral

The success of a good Doctor Patient Relationship is related to • • • • •

Amount of Information Quality of Information Accuracy of Diagnosis Effective Treatment Compliance

2. COMPLIANCE

• Definition: The extent to which a person’s behaviour (in terms of taking medications, following diets or executing lifestyle changes) coincides with medical or health advice (Sackett and Snow 1978)

• Compliance means the degree of how a person reacts to a certain kind of medicine, a diet, or a change of lifestyle in correspondence with medical advice

R. Brian HAYNES

History Following the snake’s advice can be looked at as compliance. But the consequences of taking the snake’s advice which led to a changed situation of life for Adam and Eve can be seen as noncompliance.

The 5 Dimensions of Compliance

Health care team • • • • • •

Past Experiences Motivation Relationships Communication skills Compassion Caring

Patient-Related Factors

• • • • • • •

Knowledge / Skill Health beliefs Responsibility Past Experiences Support Conflict/stress Finances

Condition-Related Factors

• Chronicity – Relapse rates

• Disability • Pain • Consequences of treatment – Symptom relief / prophylaxis – Immediacy of benefit – Side effects

• Complexity of treatment

Socio-Economic Factors

Therapy –related factor

• Access to medications • Complexity of the therapy • Immediacy of beneficial effects • Side effects

Partial Compliance

Not taking medication as prescribed • Missing doses • Drug holidays • Lower dose vs Rx

Compliance in Chronic Medical Illnesses

• Rates of compliance were only 25% for patients with diabetes • 67% for those with rheumatoid arthritis • 53% for those with hypertension

Degree of difficulty to produce complience sufficient for therapeutic effect Weight Reduction Schizophrenia Exercise Flossing Hypertension Diabetes (insulin depot) Diabetes (oral) Depression Rheumatoid Arthritis Asthma Strep Throat Birth Control Pills Headache 20 Easy

40

60

80

Keith & Kane J Clin Psychiatry, 2003; 64: 1308-1315

100 Difficult

Measurement of (non)-compliance “Simple methods are not accurate and accurate methods are not simple”

Simple

•Anamnesis •Pill counts •Prescription counts

Not simple

• Drug/metabolite concentration • MEMS (medication event monitoring system)

C (Goldsmith) or PC (patient compliance)

No of pills taken by patient PC = --------------------------------------- X 100 No of prescribed medicines

Morisky Simplified Self-Report Measure of compliance SCORING: 0 = HIGH compliance; 1-2 = MEDIUM compliance; 3-4 = LOW compliance

• Do you ever forget to take your medicine? • Are you careless at times about taking your medicine? • When you feel better do you sometimes stop taking your medicine? • Sometimes if you feel worse when you take the medicine, do you stop taking it?

Medication Event Monitoring System

Medication event monitoring system, MEMSTM: The pill bottle cap contains a micro-electronic circuit that registers when the bottle is opened. This data may then be transferred to a computer via a reading device

Consequences non compliences – Increased morbidity • Symptom exacerbation • Medical complications • School absence

– Increased mortality – Health care costs • Appointments / hospitalizations • Tests / prescriptions • Influence research

Strategies to enhance complience

• Simplifying regimen • Imparting knowlegde • Modifying beliefs • Patient communication

• Leaving the bias • Evaluating complience

Empowerment Through Education

• 1. Their Illness is serious • 2. Their Condition is essentially self- managed • 3. They Have option • 4. They Can change behavior

Barriers to compliance

Patient Constribute : – – – – – – – – – –

Forgetfullness 30% Other priorities 16 % Decision to omitdoses 11% Lack of information 9% Emotional factor 7% Poor Attitude Memory deficits Language Beliefs Alternative Health

Physicians Constribute: – Prescribing Complex Regimens – Failing to explain benefit/side effect – Cost of the Medication – Poor therapeutic relationship

Interventions to Improve Compliance Almost all studied interventions that are effective for long-term care are complex – more convenient care – information – counseling

– reminders – self-monitoring – reinforcement – Family therapy

“ The physician should always be aware of the fact that patients might be lying when saying that they took the prescribed medicine.”

DRUGS DON'T WORK IN PATIENTS WHO DON'T TAKE THEM C. EVERETT KOOP, MD

The Real Drug Problem:

Forgetting to Take Them

3. COMPLICATION Complication of DM

1. Acute: • • •

Ketoacidosis Hyperglycemic Hypoglycemic

2. Chronic: • microcirculation neuropathies, nepropathies, retinopathies

• Macrocirculation • Foot ulcer

Thank You