About the Book

Coverage of essential topics as per the syllabus in the specialty of family medicine.
Organized by typical patient encounters in family practice.
Coverage of critical issues in office practice.
Comprehensive and evidence-based information throughout.
Numerous tables make information retrieval quick and accurate.

About the Author

CS Madgaonkar MBBS FCGP

Table of Contents:
Contents Section 1: BASIC PRINCIPLES 1. Philosophy of Family Medicine 3 2. Scope of Family Medicine 8 • Three Facets of Family Practice 8 • Matrix of Family Practice 9 • Proactive Role of Family Physician 10 3. Family Medicine: The Rising Discipline 12 • History 12 • Age of Specialization 14 • Revival of Family Medicine 15 • Future 17 • Family Medicine—Need of the Hour 20 4. Definitions 22 • General Practice 22 • Leeuwenhorst Definition 22 • Changing Domain of General Practice 22 • Wonca Definition—1991 (World Organization of Family Doctors) 24 • Olesen Definition—2000 24 • The European Definitions—2005 (Wonca Europe Definitions—2005) 25 • Definition of General Practitioner 29 • Definition of Family Physician 30 • Family Practice 31 • Difference—Family Practice and General Practice 31 • Advantages of Family Practice 31 • Primary Care 32 5. The ‘Family’ in Family Medicine 37 • Focus on Family Health Care 37 • Family—Definition 37 • Characteristics of a Healthy Family 38 • Characteristics of a Disturbed Family 39 • The Family Life Cycle and Role of Family Physician 39 • Family Dynamics and Illness 41 • Family in Crisis 43 • Family-based Medical Counseling —The “Bathe” Technique 46 • Working with Families—Avoiding Pitfalls 47 Section 2: HEALTH FOR ALL 6. The Alma-Ata Declaration 51 • Background 51 • The Genesis of Alma-Ata 52 • Primary Health Care Takes Center Stage 52 • Declaration of Alma-Ata 152 xxii Family Medicine: A Clinical and Applied Orientation 7. Primary Health Care Approach to Health for All 55 • What is “Health for All”? 55 • HFA—The Fundamental Principle 55 • The Genesis of Primary Health Care 56 • The Concept of PHC 56 • Phc Definition 57 • The PHC Approach 57 • Ingredients of PHC 57 • Phc Revival—Beyound Declaration 59 Section 3: CLINICAL APPROACH 8. The Spectrum of Clinical Diagnosis 63 • Clinical Process—History and Symptomatology 64 • Clinical Process—Physical Diagnosis 67 • Sequence in Clinical Diagnosis 68 • Diagnosis in Family Practice 70 • The Differential Diagnosis 72 • Changing Conceptions of Health, Disease and Diagnosis 72 9. Investigations: General Principles 76 • Refining Clinical Diagnosis 76 • The Reason for the Test 77 • Analytical Errors 77 • Interpretation of Tests 78 • Importance of Chronological Data 81 • Right Choice of Test 81 • Gold Standard Tests 82 • Who the Investigation for: Patient or Doctor? 82 Section 4: THE PRACTICE OF FAMILY MEDICINE 10. Communication Skills 87 • Communication as a Core Competency 87 • Definition 88 • Importance of Effective Communication 88 • Key Tasks in Communication with Patients 89 • Key Communication Skills Needed to Perform Key Tasks 89 • Communication Types 91 • Communication with Children 92 • Communication with Older Patients 93 • Barriers in Communication 93 • Common Communication Pitfalls 95 • Acquiring New Skills 95 • Neurolinguistic Programming 95 11. Rapid Access to Improving Communication Skills 97 • Changing Practice Environment 98 • Refining Communication Skills 98 12. The Consultation 104 • Objectives for the Consultation 104 • Tasks in the Consultation 105 Contents xxiii • The Consultation Process 106 • Interviewing Skills 109 • Common Pitfalls when Interviewing Patients 113 • Consultations as Routines, Dramas and Ceremonies 113 • Patient Satisfaction with the Consultation 114 • Troublesome Consultations 114 13. The Physician-Patient Relationship 116 • Concepts and Changes 116 • Types 117 • Scope of Physician-Patient Relationship 118 • Ending the Physician-Patient Relationship 121 14. Balint Group 123 • Historical Origins 124 • Balint Groups 124 • Balint Training 125 • Balint Discoveries 126 15. Designing a Patient-friendly Practice 130 • Objectives to Redesign 130 • Designing the Clinic 131 • The Waiting Room and Reception 131 • The Consultation Room 132 • Staff 133 • Greeting Patients—Checking-in and Checking-out 133 • Incorporating New Technology 134 16. Counseling Skills 136 • Counseling Interventions in Primary Care 136 • Counseling 136 • Specific Areas of Counseling 138 • Counseling Procedure 139 • Counseling Strategies 140 17. Patient-centered Care 143 • Why Such Broad Use? 144 • Defining Patient-centered Care 145 • Evidence Base for Patient-centered Care (PCC) 147 • Patient’s Choice 147 • Patient-centeredness—What Determines the Physician’s Clinical Behavior? 148 • Patient-center Care Model 148 • Hypothetical Case Scenario: An Adult Diabetic 149 18. The Team Approach 153 • Need for Team Concept 153 • Personal versus Team Care 154 • Team Training: Current Status and Assessment 154 • Working with Colleagues 155 • Communication Strategies 156 • Team Cover on Off-Duty or Leave 157 19. Leadership 159 • Physicians as Leaders 159 • Changing Leadership Competency 160 • Physicians as Better Leaders 160 • Developing Physician Leaders 161 xxiv Family Medicine: A Clinical and Applied Orientation • Characteristics of Leadership 162 • Tools for Leadership 163 • What Physicians should do when Asked to Lead? 164 20. Addressing Medical Errors 168 • New Approach—Acknowledge Mistakes 169 • Medical Errors—Focus on Primary Care 169 • Definition 169 • Types of Errors 171 • Classification 171 • Understanding Errors in Family Practice 172 • Why should Doctors Disclose Medical Errors 173 • Why Doctors do not Disclose Errors 174 • System Redesign in Family Practice 175 • Apology as a System of Medical Error Disclosure 176 • Eliminating Errors in Family Practice—Current Trends 177 • How to Cope with Clinical Errors 180 • What Patients can Do 180 21. Medical Records 184 • Purpose of Record Keeping 184 • Standards in Medical Record-keeping 185 • Content and Style 185 • Practical Ways of Improving Record-keeping 186 • Weed System: Problem-oriented Medical Record (Pomr) and Soap 186 • From Soap to “Snocamp” 190 • Medical Council of India (MCI)—Importance of Medical Records 191 • Medicolegal Records 192 22. The Difficult Patient 195 • Terminology and Incidence 196 • Characterizing the Difficult Patient 197 • Who is at Fault 198 • Problems in the Physician 199 • Problems in the Physician-Patient Relationship 200 • Disorders to Consider 200 • Strategy to Handle Difficult Patients 201 • Coping Skills for Physicians 202 • Coping Skills for Family Physicians 204 • The Calmer Approach 204 23. Medical Professionalism 208 • Professionalism—Pitfalls 209 • The Evolution of Professionalism 209 • Defining Professionalism 210 • Fundamental Ethical (Moral) Principles 211 • A Set of Professional Responsibilities 212 • Model Behaviors of Professionalism 214 • Unprofessional Behaviors 215 • Reasons for Teaching Professionalism 215 • The Educational Challenge 215 Contents xxv Section 5: ADOLESCENT HEALTH 24. Adolescent Care 221 • Introduction 221 • Definition 222 • Adolescent Consultation 223 • Exploring Hidden Agenda 224 • Confidentiality 224 • History 224 • Adolescent Communication 226 • Communication Techniques 226 • Physical Examination 227 • Counseling 228 • Goals of Counseling 230 • Improving Existing Services—Adolescent Care Clinics (Acc) 230 25. A Problem Adolescent 233 • Parenting Stress 233 • Parenting Style and Problem Adolescent 233 • Behavior Problems 235 • Adolescent Depression 235 • Suicidal Risk 236 • Physician’s Role 237 • Indications for Psychiatric Referral 238 • A Scheme for Fortifying the Parent-Adolescent Relationship 238 • Guidance and Counseling to Parents 239 • Preventive Advice to Parents and Family Members 239 Section 6: GERIATRIC HEALTH 26. Aging and Geriatric Concepts 243 • Definition 243 • Demographic Revolution 244 • The Role of Family Physician 244 • Characteristics of Disease in Elderly 245 27. Comprehensive Geriatric Assessment 249 • Barriers to CGA 250 • Medical Assessment 251 • History Taking and its Pitfalls 251 • Important Specific Areas 252 • Physical Examination and its Pitfalls 254 • Investigations 259 • Mental Status Examination 259 • Functional Evaluation 259 • Advance Directive 262 28. Management of Common Geriatric Problems 264 • The “Age Wave” 264 • Paucity of Geriatric Care 265 • Geriatric Care and Family Physician 265 • Atypical Symptoms 266 • Physician’s Role 266 xxvi Family Medicine: A Clinical and Applied Orientation • Major Manifestations of Common Geriatric Problems 268 • Psychological Problems and Elder Abuse 270 • Cardiovascular Problems 271 • Respiratory Problems 273 • Gastrointestinal Problems 274 • Incontenance and Urogenital Problems 274 • Endocrine Problems 275 • Musculoskeletal Problems 276 • Falls and Balance Problems 277 • Visual Impairment 278 • Hearing Problems 279 • Nutrition 279 • Attitudes for a Successful Geriatric Practice 280 29. Practical Prescribing to the Elderly 283 • Concerns over Aging Population 283 • Prescribing Cascade 284 • Polypharmacy 285 • When should an Adr be Suspected? 286 • Principles of Good Prescribing 287 • Non-drug Therapy 287 • Begin Therapy with Clear Endpoints in Mind 288 • Treat the Disease Process Rather than Symptoms 289 • Start Low Go Slow 289 • Medication Debridement—Reducing Medications and Doses 289 • Review the Drug Profile at Every Visit 289 • Effective Communication 290 • Medication Noncompliance in the Elderly 290 • Measures to Enhance Compliance 290 • Ethical Principles 291 Section 7: PALLIATION AND BEREAVEMENT 30. Communicating Bad News 295 • What is Bad News? 295 • Why is Breaking Bad News So Difficult? 295 • Importance of Disclosure 297 • What Patients Value 297 • How Should Bad News be Delivered? 298 • Communication in Specific Situations 300 • The Future 300 31. Palliative Care: Principles 303 • Recognizing Dying 303 • The Need for Palliative Care 303 • Special Role of the Family Physician 304 • What is Palliative Care? 304 • Principles of Palliative Care 306 • Tasks in Palliative Care and Care of the Dying 307 • When Death is Approaching: Diagnosing Dying 308 • Patient—Family Involvement: Shared Decision Making 308 • Identification and Management of Symptoms 310 • Support of Family and Carers 312 Contents xxvii • Support after the Death 312 • The Limits of Care at the End of Life 313 • Summary of Tasks for the Patients in the Dying Phase 313 • Conspiracy of Silence 313 32. Palliative Home Care 316 • Caring at Home—Some Considerations 316 • Definition 317 • Home Care: Issues in Developing Countries—is There a Need? 317 • Demoralizing Syndrome 319 • Home—The Preferred Choice 319 • Involvement of Family Physician 320 • How to Get Started and Keep Going 321 • Clinical Issues 322 • Patient Issues 323 33. Family and the Grief Process 327 • What is Grief? 327 • Symptoms of Grief 328 • Features of Grief 328 • Course of Grief 329 • Types of Grief Reaction 329 • Risk Factors for Complicated Grief 330 • Family Physician as Counselor 330 • Guidelines to Manage a Grieving Person and Family Members 331 • Referral 331 Section 8: PREVENTION AND HEALTH CARE 34. Prevention in Family Practice 335 • The Power of Prevention 335 • Prevention—Family Physician’s Role 336 • Prevention—Limiting Factors 336 • Promoting Prevention 337 • Levels of Preventions and Screening 337 • Opportunity for Prevention 338 • Scope for Prevention 339 35. Preventive Care Delivery: Barriers and Remedies 346 • Overview 346 • Barriers to Prevention 346 • Solutions to Barriers 351 Section 9: EDUCATION AND RESEARCH 36. Clinical Audit 359 • Why is Clinical Audit Important? 360 • Different Between Medical and Clinical Audit 360 • Multiprofessional Clinical Audit in Family Practice 361 • Difference Between Clinical Audit and Research 361 • The Audit Cycle 361 • Steps in Clinical Audit in any Particular General Practice 362 • Keep a Record 364 xxviii Family Medicine: A Clinical and Applied Orientation • Confidentiality 365 • Audit—Pitfalls 365 37. Evidence-based Medicine: Principles 366 • A Case Scenario 366 • Case Study Continued 366 • Learning of Evidence-based Medicine (EBM) 367 • What is Evidence-based Medicine? 367 • Distinguishing Features of Ebm 367 • Where did Ebm Come From? 368 • The Rationale for Ebm—The Paradigm Shift 368 • Definition of EBM and EBP 369 • Steps to Practicing EBM 370 • Advantage of Ebm 373 • Limitations of Ebm 373 • Misconceptions about EBM 374 38. Evidence-based Medicine: Practice 376 • Evidence-based Practice 376 • Adherence of Ebp in General Practice/Family Medicine 376 • Concerns about Ebm in Primary Care Practice 377 • Essentials of EBM in Primary Care Practice 380 • The Future of EBM in Primary Care 380 39. Research in Family Medicine 384 • Background of Research in Family Medicine 384 • What Constitutes Family/General Practice Research? 385 • Types of Research Methodology 386 • Good Research in Family Practice 389 • Research Strategies for Family Medicine 390 • Aims and Objectives of Research in Family Medicine 390 • Methodology or Logistics of Research 390 • What can Family Physicians do 391 • Suggested Research Training and its Incentives Rewards 393 Appendices 395 Index 407