Department of Public Health and Epidemiology Chronic Disease Epidemiology Unit

General Practice in Medicine: A Personalized Approach to Patients Carlos Quinto Swiss TPH & General Practice

Contents • • • • • • • • • •

Overview – WONCA Tree Family Medicine Social Context History Taking Political Context Ethical Considerations Behaviour - Risk Factors Administration Working Conditions Conclusions

Family Practice • Relationship building: trust, protected area, long-term relationship • History taking: personal, family, social, environmental • Examination: physical, laboratory, RX, ultrasound

• Networking: other professionals: health, community, insurance, etc.

Large variation Communication is key

More than one generation ….

Rikard 90 years

Family Situations • Age range: 5-105 • Example: 1. Miss Murphy 53 y, Friday, 28th of November 2014 2. Father, 83 discharged from rehabilitation clinic after knee surgery 3. Mother, 80, emergency call: stroke with right hand weakness and visual field loss 4. Husband, 3 days before hospitalized after workplace intoxication, lost of consciousness, with H2S (dihydrogensulfid, >500 ppm) high dose, organizing follow up consultations etc. • Systemic approach family medicine • Data protection, but common sense: individual interests before family member interests

“The husband, his wife and his lover”: • Not a movie by Peter Greenaway, but quite frequent in family medicine • Delicate in several aspects: appointments, data protection • Background knowledge important: psychosomatic disorders  Avoid unnecessary hospitalizations and diagnostics

Social Situations Miss Gomez, 46y, cleaning worker, married, two daughters History of 4 month headache, hospital outpatient (policlinic) D: F45.40, due to work overload; myasthenia gravis F45.4 Persistent somatoform pain disorder The predominant complaint is of persistent, severe, and distressing pain, which cannot be explained fully by a physiological process or a physical disorder, and which occurs in association with emotional conflict or psychosocial problems that are sufficient to allow the conclusion that they are the main causative influences. The result is usually a marked increase in support and attention, either personal or medical. Pain presumed to be of psychogenic origin occurring during the course of depressive disorders or schizophrenia should not be included here.

Psychalgia Psychogenic: backache, headache Somatoform pain disorder

Miss Gomez (cont) First consultation: 23 Oct. 2007, came from the city, 1h public transport. Speaks very little German. In Spanish: Headache has become more severe over the last 3 weeks, wakes up at night, mild nausea. Examination: No neurological deficits. DD: Not psychosomatic, viral infection (lab), cerebral neoplasia,… No change in 3 days: MRI Scan 31 Oct.: Stenosing process in Tectum: Aquaeductum obliteration by cystic unclear process. Cerebrospinal fluid circulation severly disturbed. Neurosurgery Department: Ventriculo-peritoneal shunt, 2nd of November Key Point: Just listening 90 seconds to patient‘s own history in her language: Spanish. Red flags.

History Taking Language is key for appropriate history taking A yw Cymraeg cyn hawsed â Sbaeneg? ceann goirt Buruko mina dut Fejem Minulla on päänsärky

Relationship and communication are crucial in primary care and neglected in economical driven public health scenarios

Political Context Personalised Medicine WHO can afford it? Industrialised Medicine for all and Personalised Medicine for a few ETH Gesundheitsgespräch 1st of October 2014 Contributions of basic research to health Discussion: more industrial standards (Peters, FOPH) vs personalized medicine (Zünd, USZ): http://www.multimedia.ethz.ch/misc/2014/gesundheitsgesprae ch/?doi=10.3930/ETHZ/AV-c38537ef-bee1-496a-add5ab7c2e3c26c6&autostart=true 42. minute ff

Ethical Considerations Health – To Have or To Be? „incurvatus in se ipse“

C. Aus der Au: SAEZ 2014;95: 37

Open questions:  Pregnant women and children?

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Generic drugs: No race to the bottom!?

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Frequent diseases in poor populations?

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Orphan diseases?

MIND THE GAP

Putting all together…. Patient, NN, 1999-2011  69 years, male, single, house, 1 cat  social: two children, living abroad  Outpatient: spitex, podology, food service, cleaning service, specialist consultations (pacemaker,…),…  2007 nursing home inpatient  2002 Mamma Carcinoma pT4 pN1b (3/13) Mx G3 (surgery, tamoxifen)  2005 Chronic lymphatic leucemia (B-CLL), Rai Class:0 (watch and wait, active surveillance)  2008 Lentigo maligna Melanoma Breslow 3.4mm, Clark Level V (surgery)

Further Problems  1962 insuline dependent diabetes: nephropathia, neuropathia, retinopathia  1995 aortic valve prothesis, pacemaker: oral anticoagulation  Hypertensive, coronary and valvular heart disease  Hyperlipidemia: intolerance of all statins  Osteoporosis: bone fractures  Prostate: hyperplasia  Dementia, vascular: mild  Presbyakusis  Died 2011 (81 yrs) because of hospital acquired respiratory infection after fall with vertebral fractures

Primary care is complex

 Medication list: 12 medications (guidelines: 24)  Quality of life: eye problems (car driving), hearing loss, heart insufficiency, skin care, pain (not permanent), no amputations

Drug Interactions

Behaviour - Risk Factors Motivational Interviewing

Motivational Interviewing (MI) (William R. Miller, Stephen Rollnick)

 MI is a person-centered counseling style for addressing the common problem of ambivalence about change

 Spirit of MI: Collaboration, Acceptance, Compassion, Evocation    

Engaging, Focusing, Evoking, Planning Follow: listen, 90 seconds shut up! Guide: ask Direct: inform

People are generally better persuaded by the reasons which they have themselves discovered than by those which have come into the mind of others. Blaise Pascal

PLoSMed 5(1): e12. doi:10.1371/journal. pmed.0050012 Published: January 8, 2008

Preventive Medicine 65 (2014) 148–152

PLoSMed 5(1): e12. doi:10.1371/journal. pmed.0050012 Published: January 8, 2008

Administration/Health Insurance Chorea Huntington Genetic disorder, chromosome 4 Proteine Synthesis Degeneration of neurons: lost of locomotor control, incl. speech, impaired ability to swallow. Personality changes, dementia

Prevalence: ca. 400 people in CH Men, autosomal dominant 40-50 y first symptoms Next generation?

Needs support:

Physiotherapy, logopedics, ergotherapy, special food, special chairs, bed, language support system, (wheel)chairs, incontinence pants, ….. Health insurance: Physio: Will the disorder be healed in the next two months??!! Answer:

(2014: 2 A4 pages: Please justify extensively, if not)

 „Please look up, what Chorea Huntington is in wikipedia, before you send the next form.“  Estimated 1/3 of all insurance requests is medical nonsense (only exception: SUVA).

 52 year old man  disease started 2005, diagnosis 2006 genetically confirmed in university hospital  Several hospitalisations (aspiration, patient has a percutaneous endoscopic gastrostomy tube)  Specialized nursing home, physiotherapy, logopedics, ergotherapy neurologist (medication), family practice (monthly meeting with responsible nurse, laboratory controls, coordination, correspondence, …).

Special wheelchair

Working Conditions National Health System •

Switzerland: primary care is mainly privately organized, cantonal rules: 26 health systems for 8 Mio. people

•

No 10 minutes slots (NHS). “Only one problem per consultation please”

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Some consultations only take 5 minutes, most 15 minutes, 2 up to 3 problems have to be solved.

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Sometimes we need 1 hour, planned in advance.

In one consultation could be addressed: Health promotion

Behaviour 1

Primary prevention

Behaviour 2

Diagnostics

Family history/Concern 1

Therapy

Concern 2/Disease 1

Rehabilitation (tertiary prevention)

Disease 2/Behaviour 3

Quarternary prevention

Concern 3/Illness 1

Palliative care

Disease(s): a to n

(secondary prevention/case finding)

(smarter medicine)

Doctor’s side

Prevention levels

Patient’s side

Level

Disease

absent

present

absent

Primary prevention illness absent disease absent

Secondary prevention illness absent disease present

present

Quaternary prevention illness present disease absent

Tertiary prevention illness present disease present

Illness

Definition

Primary prevention

Methods to avoid occurrence of disease. Most population-based health promotion efforts are of this type.

Secondary prevention

Methods to diagnose and treat extant disease in early stages before it causes significant morbidity.

Quaternary prevention

Methods to mitigate or avoid results of unnecessary or excessive interventions in the health system.

Tertiary prevention

Methods to reduce negative impact of extant disease by restoring function and reducing disease-related complications.

Offre et recours aux soins médicaux ambulatoires en Suisse – Projections à l‘horizon 2030; 2008; document de travail 33

2030: lack of GP consultations 9.29 Mio. (5.50 – 13.78) 3400 per year and m GP: 1786 1800 per year and f GP: 1786

2007

27.11.14 WDA: 40‘000 -140‘000 Health Professionals are lacking in CH in 2030!

2030: lack of 120‘000 -190‘000 nurses 2/3 due to ageing workforce 1/3 due to ageing population Shortness of GPs will put pressure on nurses

Conclusions  

Family Medicine is Personalised Medicine on a macro-level No end of the pipe solutions!

Difficulties we face:  Industrial concepts of economists  Limited medical experience and knowledge 



No understanding of fundamental values and the language of medicine GP knowledge limitations (Public Health, ….)

Hope:  Mutual learning and understanding  Identify the gaps and build bridges

Thank you  To my patients  To Monica Lindh, Sweden  To my colleagues Jörg Fritschi and Andreas Käppeli and our MPAs of Praxis Pfeffingen  To Ueli Grüninger and Stefan Neuner, Swiss College of Primary Care Medicine  To Nicole Probst-Hensch , Nora Bauer Ott and all colleagues from the CDE Unit  To my family