Medical Social Integration from a Family Doctor ’ s Perspective.

Medical Social Medical Social Integration from Integration from a Family Doctor’s a Family Doctor’s

PerspectivePerspective

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

• Why family doctors are in the best position Why family doctors are in the best position to deliver community elderly care?to deliver community elderly care?

• Case example to demonstrate why medical and Case example to demonstrate why medical and social integration is necessary for the delivery of social integration is necessary for the delivery of optimal community elderly care.optimal community elderly care.

• What are the obstacles of providing elderly What are the obstacles of providing elderly cares by family doctors?cares by family doctors?

What are the differences between What are the differences between caring for a sick elder and a sick caring for a sick elder and a sick

young adult?young adult?

• Elderly patients commonly have multiple Elderly patients commonly have multiple problems, including medical, mental and problems, including medical, mental and social conditions. Chronic illnesses also are social conditions. Chronic illnesses also are more common in the old population.more common in the old population.

• The elders have decreased reserve The elders have decreased reserve capability.capability.

• The presentation of a sick elder is The presentation of a sick elder is commonly atypical.commonly atypical.

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

• When people get old, changes in When people get old, changes in body composition make older people body composition make older people more vulnerable to adverse drug more vulnerable to adverse drug reactions. reactions.

• The intellectual decline, together with The intellectual decline, together with multiple physical deficits will cause multiple physical deficits will cause problems in communication. problems in communication.

• Caring for frail elders requires both Caring for frail elders requires both multidimensional and multidimensional and multidisciplinary management.multidisciplinary management.


• The elderly population is heterogeneous. That is to The elderly population is heterogeneous. That is to say, for the same age group of elders, their health say, for the same age group of elders, their health status is not uniform and there is tremendous status is not uniform and there is tremendous variation. variation.

• As people age they become more individual As people age they become more individual and differentiated. There is increasing and differentiated. There is increasing variability with age - among individual and variability with age - among individual and among levels of functioning from day to among levels of functioning from day to day.day.

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

• Because of this variability, chronological Because of this variability, chronological age per se has lost its meaning as a marker age per se has lost its meaning as a marker of personal capacity. of personal capacity.

• As a general rule while managing sick As a general rule while managing sick elders, care becomes more important than elders, care becomes more important than cure and function more important than cure and function more important than diagnosis. diagnosis.


Comprehensive Geriatric Functional Assessment

BEHAVIORAL

COGNTIVE

GAIT/BALANCE

PHYSICAL

QUALITYOF LIFE

ECONOMIC

SOCIAL

PHYSICALENVIRONMENT

PSYCHOLOGICAL

FUNCTIONALSTATUS


• In the care of elderly patients, family In the care of elderly patients, family members provide the majority of care members provide the majority of care necessary to keep their frail elders in the necessary to keep their frail elders in the community. community.

• Therefore, a visit to the doctor’s office often Therefore, a visit to the doctor’s office often includes the family caregiver accompanying includes the family caregiver accompanying the elderly person. Thus the doctor-patient the elderly person. Thus the doctor-patient encounter, which is commonly dyadic encounter, which is commonly dyadic becomes triadic. becomes triadic.


• The role of the caregiver during these visits may not The role of the caregiver during these visits may not always be predictable: it may be facilitative , always be predictable: it may be facilitative , supportive or neutral. It can also be antagonistic, such supportive or neutral. It can also be antagonistic, such as the co-opting of an agenda to meet the caregiver’s as the co-opting of an agenda to meet the caregiver’s own needs. Therefore, doctors need to have good own needs. Therefore, doctors need to have good communication skill in triadic encounter.communication skill in triadic encounter.

• Furthermore, in the care of their elderly patients, Furthermore, in the care of their elderly patients, doctors may find themselves not only assisting doctors may find themselves not only assisting caregivers in problem-solving and referral to caregivers in problem-solving and referral to community resources but also assessing the community resources but also assessing the caregiver’s health and coping skills. caregiver’s health and coping skills.


• Caring for elders is stressful; the caregiver is Caring for elders is stressful; the caregiver is encompassed with the physical, social, psyencompassed with the physical, social, psychological, and financial toll of providing cachological, and financial toll of providing care. The caregivers become the “hidden victre. The caregivers become the “hidden victims”. ims”.

• Recent finding has shown that family caregiRecent finding has shown that family caregiving is an independent risk factor for mortalving is an independent risk factor for mortality among elderly spousal caregivers.ity among elderly spousal caregivers.


• Informal caregivers have a higher level of Informal caregivers have a higher level of depression, more likely to experience depression, more likely to experience physical pain, and more likely to experience physical pain, and more likely to experience financial stress.financial stress.

• Failure by doctors to recognize the burden Failure by doctors to recognize the burden on informal caregivers may result in long on informal caregivers may result in long term adverse outcome on this group that term adverse outcome on this group that may outweigh the benefits of managing may outweigh the benefits of managing people with disability and chronic illness in people with disability and chronic illness in the community.the community.


• Caring for the caregiver, thereby Caring for the caregiver, thereby reducing caregiver burden and helping reducing caregiver burden and helping with care-recipient problems, could result with care-recipient problems, could result in great benefit for the patient, informal in great benefit for the patient, informal caregiver and for the larger community. caregiver and for the larger community.

• Doctors who look after the family and Doctors who look after the family and know the family function well, they are know the family function well, they are most suitable in the healthcare systems most suitable in the healthcare systems to assist both the frail elderly and their to assist both the frail elderly and their family informal caregivers.family informal caregivers.

Why family doctors are in the best Why family doctors are in the best position to deliver community elderly position to deliver community elderly care?care?

• Are readily available and affordable.Are readily available and affordable.

• Are accustomed to provide holistic and family care.Are accustomed to provide holistic and family care.

• The family doctor seeks to understand the context The family doctor seeks to understand the context of the illness. Many illnesses cannot be fully of the illness. Many illnesses cannot be fully understood unless they are seen in their personal , understood unless they are seen in their personal , family and family and social contextsocial context. When a patient is . When a patient is admitted to the hospital, much of the context of the admitted to the hospital, much of the context of the illness is removed or obscured. Therefore, it is not illness is removed or obscured. Therefore, it is not unreasonable for hospitalized elders request their unreasonable for hospitalized elders request their family doctors to pay visits to them.family doctors to pay visits to them.


• Family doctors provide continuity of care Family doctors provide continuity of care and there is evidence that continuity of and there is evidence that continuity of care is associated with patient satisfaction, care is associated with patient satisfaction, decreased hospitalizations and emergency decreased hospitalizations and emergency department visits and improved receipt of department visits and improved receipt of preventive services.preventive services.

• The family doctor views his or her practice The family doctor views his or her practice as a “population at risk.” Always think as a “population at risk.” Always think patients in terms of both as single and patients in terms of both as single and population groups. This concept is population groups. This concept is important for the delivery of anticipatory important for the delivery of anticipatory care.care.


• They have earned trust from the They have earned trust from the family long before seeing the family long before seeing the patient.patient.

• They have owned comprehensive They have owned comprehensive knowledge of their patients.knowledge of their patients.

• They practice patient-centered They practice patient-centered communication in such a way that it communication in such a way that it is correlated with the patient’s and is correlated with the patient’s and caregiver’s perception of finding caregiver’s perception of finding common ground.common ground.


• They practice learnt communication skills They practice learnt communication skills (triadic encounter, poor historians).(triadic encounter, poor historians).

• They are used to deliver coordinated care.They are used to deliver coordinated care.• They are frontline doctors therefore they They are frontline doctors therefore they

are in the best position to offer preventive are in the best position to offer preventive care and functional geriatric assessment.care and functional geriatric assessment.

• They are keen to establish good patient-They are keen to establish good patient-doctor relationship since it has always doctor relationship since it has always been their first priority.been their first priority.

• They advocate the practice of evidence-They advocate the practice of evidence-based medicinebased medicine

Case example to demonstrate the Case example to demonstrate the importance of medical and social importance of medical and social integrationintegration

• Mrs. Lau a 72-year-old, type II diabetic.Mrs. Lau a 72-year-old, type II diabetic.

• Caregiver for her husband who is also Caregiver for her husband who is also one of my patients.one of my patients.

• Mr. Lau, in addition to coronary artery Mr. Lau, in addition to coronary artery disease, has hypertension, disease, has hypertension, osteoarthritis, cataract, gout, anxiety, osteoarthritis, cataract, gout, anxiety, and had a stroke three years ago.and had a stroke three years ago.


• She complained to me during one of the regulShe complained to me during one of the regular follow ups that she was getting tired easily, lar follow ups that she was getting tired easily, losing weight, and lack interest in many things osing weight, and lack interest in many things despite good blood glucose level control. despite good blood glucose level control.

• I routinely enquired for caregiver stress, she suI routinely enquired for caregiver stress, she suddenly bursted into tears and frankly admitteddenly bursted into tears and frankly admitted that she was disturbed by her husband’s ud that she was disturbed by her husband’s unusual behaviour. nusual behaviour.


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

The analysisThe analysis

• The longstanding doctor-patient relationship and The longstanding doctor-patient relationship and knowledge of the medical and social background of knowledge of the medical and social background of the family helped me to spot the following problems.the family helped me to spot the following problems.

• Mrs. Lau’s family, in addition to the underlying Mrs. Lau’s family, in addition to the underlying medical problems, there were undetected new medical problems, there were undetected new medical problems and social problems.medical problems and social problems.

• In this case, the new medical problems had emerged In this case, the new medical problems had emerged as a complication of her husband’s underlying as a complication of her husband’s underlying medical diseases.medical diseases.

The analysisThe analysis

• The new medical problems were:The new medical problems were: Dementia and depression Dementia and depression which are common in elders with multiple chronic which are common in elders with multiple chronic

diseases, especially those with a history of diseases, especially those with a history of stroke.stroke.

• The social problems were:The social problems were: Caregiver stress.Caregiver stress. Imminent family breakdown.Imminent family breakdown. Mr. Lau would have to be transferred to OAH Mr. Lau would have to be transferred to OAH

against his will.against his will.

The managementThe management

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

The managementThe management

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

The importance of medical and social The importance of medical and social integrationintegration

• Had I not enquired about the social Had I not enquired about the social situation (caregiver stress), I would situation (caregiver stress), I would have missed Mr. Lau’s medical have missed Mr. Lau’s medical problem. problem.

• On the other hand, the social problems On the other hand, the social problems would not have been solved unless the would not have been solved unless the medical problem was detected and medical problem was detected and managed.managed.

The importance of medical and The importance of medical and socialsocial integration integration

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

What are the obstacles of providing What are the obstacles of providing geriatric cares by family doctors?geriatric cares by family doctors?

• The private family doctor do not have The private family doctor do not have sufficient government support.sufficient government support.

• By and large, continuity of care is not By and large, continuity of care is not viewed important in the care of elderly viewed important in the care of elderly patients both by the public and patients both by the public and government.government.

• The one way referral system The one way referral system preposterously operating in Hong Kong , preposterously operating in Hong Kong , makes it extremely difficult for family makes it extremely difficult for family doctor to manage and follow sick elders.doctor to manage and follow sick elders.


• The family doctors do not have The family doctors do not have interdisciplinary team support which is often interdisciplinary team support which is often required for the care of elderly patients.required for the care of elderly patients.

• There are few if any, private and public There are few if any, private and public health care services integration.health care services integration.


• Do not have adequate geriatric medicine Do not have adequate geriatric medicine training. Fortunately, there are courses like training. Fortunately, there are courses like PDCG and PDCPM in Hong Kong that can help to PDCG and PDCPM in Hong Kong that can help to supplement the family doctors’ knowledge.supplement the family doctors’ knowledge.

• Ageism exists even among medical Ageism exists even among medical professionals. Comments such as old people are professionals. Comments such as old people are all similar and there is little value of doing all similar and there is little value of doing anything for them are often heard.anything for them are often heard.

• Communication problem resulting from Communication problem resulting from cognitive impairment is one of the many cognitive impairment is one of the many reasons why doctors are reluctant to see elderly reasons why doctors are reluctant to see elderly patients.patients.


• Family doctor’s role in OAH is made in Family doctor’s role in OAH is made in such a way that it is replaceable and such a way that it is replaceable and expandable. He is not sharing the expandable. He is not sharing the leadership role in the management.leadership role in the management.

• Provision of preventive services by family Provision of preventive services by family doctor is difficult because of financial doctor is difficult because of financial constraint.constraint.

• Time constraint. Time constraint. • Reimbursement and remuneration.Reimbursement and remuneration.

ReferencesReferences• 1. The dementia caregiver-a primary care a1. The dementia caregiver-a primary care a

pproach. Stuti Dang et al, South Med J. 200pproach. Stuti Dang et al, South Med J. 2008 Dec; 101(12):1246-51. 8 Dec; 101(12):1246-51.

• 2. Family medicine attributes related to sati2. Family medicine attributes related to satisfaction, health and costs, Mireia Sans-Corrsfaction, health and costs, Mireia Sans-Corrales et al., Fam Pract. 2006 Jun;23(3):308-16.ales et al., Fam Pract. 2006 Jun;23(3):308-16.

• 3. Physician Perspectives on the elderly pati3. Physician Perspectives on the elderly patient-family caregiver-physician encounter. ent-family caregiver-physician encounter. Mark J. Yaffe et al., IMAJ 2002;4:785-789Mark J. Yaffe et al., IMAJ 2002;4:785-789

• 4.The physician’s role in nursing home car4.The physician’s role in nursing home care: an overview. M E Williams, Geriatrics 1990 e: an overview. M E Williams, Geriatrics 1990 Jan;45(1):47-9.Jan;45(1):47-9.

• 5. A textbook of family medicine, 2nd editio5. A textbook of family medicine, 2nd edition, Ian R McWhinney.n, Ian R McWhinney.

Medical Social Integration from a Family Doctor ’ s Perspective.

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