MEDICAL UNIVERSITY

1
10 YEARS GENERAL MEDICINE
MEDICAL UNIVERSITY PLEVEN, BULGARIA FACULTY
OF PUBLIC HEALTH
2
The mission...
Realizing Primary Health Care
The symbol of General Practitioners /Family
Doctors in Bulgaria Rev. General medicine ,
Sofia,1999, tom I, Nr 1, page 2.

• QUALITY OF LIFE
• and
• GENERAL/FAMILY MEDICINE
• M. Goranov, MD, PhD, Chairman of BATGP

AN IDEA WHOSE TIME HAS COME !
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Back to the future!
GPs FOR QUALITY OF LIFE !
The profound changes now occurring in medicine
can only be fully understood if they are viewed
from the perspective of history. There is
nothing new about change medicine has been
changing constantly since its beginnings. Only
the pace is different. (Ian McWhinney, A
Textbook of Family Medicine, New York-Oxford,
1997).
European Health Care Reform
4

• mission
• /lat. missio action,
  burden, load/
• WARRANTY.
• WARRANT OF ATTORNEY FOR SOMEONE
  TO REALIZE SOMETHING.
• CONSECUTION OF INSTRUCTIONS FOR LOYAL,
  DEVOTED AND TRUSTWORTHY OR PRESCRIPTIONS FOR
  CONVERSION OF SINNERS.
• LEGATION.
• MISSIONARYS RULES.
• 
  
  
  
  (Petit
  Larousse, Paris, 1966)
  
  
  
  
  
  
  

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THE MISSION of medicineGeneral/Family medicine
today

• THE MISSION OF HUMAN MEDICINE TODAY
• TO IMPROVE THE QUALITY OF ACTIVE
  LONGEVITY
• TO BUILD UP and firmly consolidate
  strengthening
• HEALTHY LIFE STYLE, to preserve and to
  reestablish it
• TO INVESTIGATE AND MASTER ILLNESS and
  DISEASE
• TO PROTECT, TO CARE and TO CURE PEOPLE.

THE MISSION OF GENERAL/FAMILY MEDICINE TODAY

• BASED ON HOLISTIC APPROACH
  /bio-psycho-social/ and
• working in a team with other medical and
  non-medical services,
• to competently offer MULTIDISCIPLINARY
  HEALTH CARE to
• persons, families and communities,
• SOLVING NOT ONLY MEDICAL but HEALTH
  PROBLEMS too !

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THE MISSIONGENERAL or FAMILY MEDICINE

• That was what made family practice unique
• among others clinical disciplines, this is
  an idea of
• THE FAMILY AS ONE PATIENT
• Epistemological, family medicine is the name
  of body
• of special knowledge and particular
  approaches that
• includes the family, but much else besides

Since the moment in which other clinical
disciplines, captivated by laboratories, high
technologies and analytical methods, deserted
permanent, closely integrated and daily
exhaustive health problems of the individual,
of the family and of the community, ONLY
FAMILY MEDICINE IS THE ACADEMIC
DISCIPLINE, which is in its rights to closely
accompany and particularly attend upon
them. ...And to resolve them in its proper
HOLISTIC APPROACH.
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THE MISSIONPHC General/Family medicine

• APPROPRIATED TO OUT-HOSPITAL HEALTH NEEDS,
  INCREASING LIFE EXPECTANCY AND QUALITY OF
  LIFE,
• GENERAL MEDICINE OF TODAY
• REPREZENTS A SEPARATE
  CLINICAL DISCIPLINE,
• EQUAL TO OTHER
  HOSPITAL DISCIPLINES.
• AS A NEW SCIENCE, THIS DISCIPLINE EXPLORES
  A
• NON-TRADITIONAL SPECIFIC
  SETTINGS OF
• 
  - NEW KNOWLEDGE,
• 
  - NEW SKILLS and
• 
  - NEW ATTITUDES.
• FAMILY MEDICINE IS A BRANCH, A HIGHER EVOLUTIVE
  LEVEL,
• BASED ON THE BEST OF GENERAL
  MEDICINE.

DO WE REIGN OVER THIS OLD NEW SCIENCE ?
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THE MISSIONGeneral/Family medicine - Specifics

• AS A MULTIDISCIPLINARY AND POLIVALENT
• CLINICAL SPECIALITY OF PRIMARY HEALTH CARE,
  
• I. E. A
  SPECIALITY OF OUT- HOSPITAL HEALTH CARE,
  
• AND SOLVING SOME
• SOMATIC AND PSYCHOLOGICAL MEDICAL
  PROBLEMS,
• GENERAL/FAMILY MEDICINE SHARES ITS TERITORY
• WITH OTHER CLINICAL DISCIPLINES,
• 
  WITH OTHER HOSPITAL SPECIALITIES.
• BUT !
• IN PHC, GENERAL/FAMILY MEDICINE USES
  HOSPITAL AND YET
• CUMULATIVE KNOWLEDGE AND SKILLS IN
  APPROPRIATE,
• 
  UNIQUE AND
• 
  UNREPEATABLE
  MANNER,
• REFINING ENRICHING HUMANIZING THEM WITH NEW
  APPROACHES.

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THE MISSIONGM/FM Holistic approach

• WHY appropriate?
• WHY unique?
• WHY unrepeatable?
• WHY ?...
• WHY ?...
• WHY ?...

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THE MISSIONGM/FM - Primary Health Care

• BECAUSE there ARE DIFFERENT
• Patients health needs and expectations in
  out-hospital medicine
• Political, economical and social order for
  Primary Health Care
• Manners of doctor-patient communication -
  hospital and out-hospital
• Delimitation of some terms as disease,
  illness, anticipatory care
• Contrivances for definition of health
  status or un-organized illness
• Meanings of, and approaches to symptom,
  health problem, diagnosis
• Patients unrestricted choice - of doctor,
  treatment, behavior or dependence
• Patients autonomy as personality - as a
  social and not only biological entity
• Practical use of relationships - problems and
  pitfalls bereavement counseling.

HEALTH PROMOTION AND DISEASE PREVENTION,
REGARDED AS PART OF A CONTINUUM, HAVE THE
COLLECTIVE AIMS OF WHICH ARE 1. TO IMPROVE
QUALITY OF LIFE.

2. TO REDUCE BURDEN OF PREMATURE
DISABILITY.
3. TO INCREASE
LIFE EXPECTANCY.
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THE MISSIONGENERAL/FAMILY DOCTOR - DEFINITION

• The general practitioner or family physician is a
  licensed specialist who is primarily responsible
  for providing personal, continuing and
  comprehensive care for everyone seeking health
  care for the individual in the context of
  family and for the family in the context of the
  community - irrespective of race, religion,
  culture or social class irrespective of age,
  sex and/or diagnosis.
• He is a synthesis of these functions, which is
  uniquely He is clinically competent to provide
  the greater part of care after taking into
  account cultural, socioeconomic and psychological
  background He deserves his patient home, in
  office, sometimes in hospital ether directly,
  either through the services of others His
  first aim is to make early diagnosis.
• He includes and integrates in his work physical
  /biological/, psychological /mental/ and social
  factors in his consideration about health
  and illness.
• He makes the initial decision about every
  health problem /differentiated or not/.

The General Practice is a continuing fluent
manifestation of classical practice in
medicine, deeply rooted in the history of
humanity and actually irrevocably linked with
the family. /Definition of American Academy
of Family Doctors/
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THE MISSIONGP/FD and Health care -
ALGORITHM
KEY POZITIONS Gate-kipper - to specialist
and/or hospital Bridge-builder - with other
medical services Team-worker and major
coordinator in PHC. ?EY FUNCTIONS First
clinical decision making /problem solving/
Engaged with patients problems to the
end Realizing health promotion, prevention,
education. ?EY SKILLS AND ATTITUDES Personal
ity-oriented /bio-psycho-social approach/
Family-focused /solving all problems in
context/ Community-relevant /beyond individual
problems/. ?EY ABILITIES Care-manager /for
allocation of scarce resources/ Fund-holder
/../ Advocacy role /working with
other authorities/.
What is needed in PHC is knowledge of
initial and characteristic symptoms of
suffering or/and illness, so that GPs are
able to estimate the health status, the
gravity of situation or disease, the alarm
signals of the latent distress, even in
cases where no diagnosis can be made
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THE MISSION...GM/FM New knowledge and skills
for
WHY ?
WHICH?

• IN ORDER TO REALLY IMPRUVE QUALITY OF LIFE,
  GP/FDs NEED
• WIDE GENERAL CULTURE
• AND ALSO SPECIFIC UNDERSTANDING IN
• Cultural anthropology /ethnos, traditions,
  religions, education/
• Sociology /occupation, home, environment,
  customs, hobbies/
• Psychology /insight, empathy, spiritual
  influence, emanation/
• Behavioral sciences /motivations, reactions,
  causality of illnesses/
• Family dynamics /aspect, function, phase,
  cycle, assessment of family/
• Interpersonal skills /compassion, charisma,
  communication/
• ?thics, aesthetics... value system etc.

Patients and doctors are actors in a play
written by history, directed by culture,
produced by politics. /Per Fugelli, 1995/


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???????...GM/FM The winds of change
The man who translates the hieroglyphics
of the science into the plain language of
healing, certainly is the most useful. Sir
William Osler
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Educating the general medical practitioner of
the 21st century

• Education for Competence
• Education for Confidence
• Education for Co-operation.
• 
  

(The European Society of General
Practice/Family Medicine RCGP)
because
WE CAN SEE ONLY WHAT WE KNOW AND
FOR WHAT WE HAVE BEEN TRAINED AND
EQUIPED
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THE MISSION...GPs/FDs for QoL

• There is no man in the world who knows
  all about medicine.
• We have to learn to discover that our
  patients, their illnesses
• and its meanings are much more than
  biological, pathological
• and pharmaceutical facts.
• We have to learn how to understand the
  patient as a part
• and in unity of his/her family against his
  social background
• To analyze the ways in which these
  two factors influence
• his/her Quality of Life.
• Only then we will be able to use in
  full value our medical
• knowledge and skills
  
  
  
  
  
• 
  
  
  
  Carl Whitehouse, 1998
• 
  
  
  Emeritus Professor, Doctor Honoris Causa of
  MU-Pleven.
  
  
  
  

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THE MISSION...GM/FM The confidentiality
The confidence of the physician
If you do not believe in Yourself, how can
you expect other people to do so? If
you have not an abiding faith in the
profession, you cannot be happy in it.
Learn to see, learn to hear, learn to
feel, learn to smell, and know that by
practice alone you can become an
expert.






Sir William Osler
It is much more important to know what
sort of patient has a disease than what
sort of disease a patient has.



Sir William Osler
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THE MISSION...GM/FM - Management of health
problems

• MANAGEMENT DECISIONS IN PHC
• ARE MADE ON THE BASIS OF PROBABILITY AND
  INVESTIGATIONS
• USED WITH DUE REGARD TO THEIR SENSITIVITY AND
  SPECIFICITY
• AND MAY BE DIFFERENT FROM THOSE
• WHICH ARE USEFUL IN HOSPITAL-BASED PRACTICE
• THE PLAN OF ACTION
• NEGOTIATED WITH THE PATIENT IS ADDRESSED TO
  
• THE NATURE OF SUFFERING - NOT ONLY TO
  ETIOLOGY
• THE PATIENT AS A PERSONALITY - NOT ONLY AS
  A BIOLOGICAL ENTITY
• THE SOCIAL CONTEXT - SEEING DISEASE AT AN
  EARLY STAGE,
• 
  BEFORE the FULL CLINICAL
  PICTURE HAS DEVELOPED.

Care more particularly for the
individual patient than for the special
features of the disease. Sir William
Osler
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THE MISSION...GM/FM Autonomy and/or
paternalism for QoL

• IN PHC, SUCCESSFUL MANAGEMENT OF HEALTH
  PROBLEMS REQUIRES
• a negotiated plan, achieving a
  doctor-patient consensus
• in which the patient has ownership and
  understanding.
• Negotiation usually involves pragmatic
  compromise
• OVER A THEORETICAL ACADEMIC, CLINICAL IDEALS
  AND DOGMAS
• IN FAVOUR OF WHAT IS POSSIBLE, REAL,
  FEASIBLE AND USEFUL
• in the patients social, family and
  personal context
• /emotional psychological intellectual -
  volitional/.

• AMONG GENERIC ISSUES OF ETHICAL DILEMMAS
• POSED BY AN AGING SOCIETY AND FACED BY
  PROFESSIONALS, ARE
• RESPECT /autonomy, self-determination, informed
  consent, paternalism?/
• BENEFICENCE /assessing risk and benefits/
• AND JUSTICE /just ways to distribute
  burdens and benefits/,
• TAKING INTO CONSIDERATION
• THE USE OF CHRONOLOGICAL AGE AS A
  CRITERION IN THE ALLOCATION OF SCARCE
  RESOURCES
• THE ROLES OF FAMILIES, PATIENTS, AND
  MEDICAL PERSONENELS IN DECISIONS TO
  LIFE-TREATEMENT
• LIMITS ON PATIENT/CLIENT AUTONOMY IN
  DECISION MAKING
• RELATIONSHIPS AMONG HEALTH-CARE PERSONNEL
  AND SOCIAL SERVICE PROVIDERS
• THE USE OF OLDER SUBJECTS IN BIOMEDICAL,
  BEHAVIOURAL, AND SOCIAL RESEARCH. /University
  of Vermont/

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THE MISSION...GM/FM - Negotiating with the
patient

• NEGOTIATION IN GENERAL PRACTICE IS A
  COMPROMISE
• BUT THE OTHER NAME OF THIS COMPROMISE IS
  FINDING
  
• FINDING THE DECISION APPROPRIATED TO THE
  PATIENT
• 
  IN HIS/HER SOCIAL, FAMILY AND PERSONAL
  CONTEXT
• FINDING THE SPECIFIC AND SHARED STRATEGY
  OF ACTION,
• 
  AND NOT NECESSARILY HOSPITAL, BIO-MEDICAL
  STEREOTYPS
• FINDING THE PROBLEM - ORIENTED
  CONSULTATION,
• AND
  NOT ONLY PRACTICING DIAGNOSTIC-ORIENTED
  MEDICINE !
• FINDING THE PATIENT - CENTERED MEDICINE
• AND
  NOT ONLY DOCTOR - CENTERED !
• AND AT LAST ...
• FINDING THE MEDICINE OF TRUE THINGS

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THE MISSIONGM/FM... medicine of true
things
The Doctor (1891) By Sir Luke Fildes 1843-1927
The GP/FD must be an advocate of the human right
to be imperfect
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THE MISSION...GM/FM Cultural and spiritual
aspects
Practicing doctors must be able to think about
and freely to discuss not only clinical but
also cultural aspects as well as those questions
which are related to religion and religious,
ethical and moral implications in health care
(e.g. food of Muslims or Jews, blood transfusion
and Jehovah followers, etc.) because
SUFFERING KNOWS NO FRONTIER PEOPLE SUFFER
INDIVISIBLE WITH THEIR WHOLE SELVES PHYSICAL,
MENTAL and SPIRITUAL. ONE OF THE MOST COMMON
ERRORS WE MAKE AS PHYSICIANS IS TO TREAT PAIN
BUT IGNORE OTHER DIMENSIONS OF SUFFERING
PHYSICAL ILLNESS IS ASSOCIATED WITH
SPIRITUAL SUFFERING SPIRITUAL SUFFERING MAY
BE MANIFESTED AS PHYSICAL OR MENTAL ILLNESS
General medicine is a ??dicine of the whole
person. This means that as physicians, we must
attend not only on their physical complaints or
on their somatic problems, but sensitively
include an awareness of their cultural and
spiritual convictions and without imposing
them on people whether pious or not
to affirm sensible
religious values.
P R I M E (Partnership in International Medical
Education) is an organization, where in
conformity with the Burrswood culture of healing,
physicians and of Jesus ministry focused on
spiritual awareness in secular professional
environments, exploring the interface between
mind and spirit in patient-centered holistic
approach, realizing the real whole-person
medicine. www.prime-international.org.uk
The greatest sin to our human brothers is
not hating them but being indifferent to
them. This is the real substance of
inhumanity. /Bernard Shaw/
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THE MISSION...GM/FM Evidence based medicine in
PHC
Unitas, Libertas, Caritas

(Uytenbogaert, anti-dogmatic theologian, ?V??-th
century)
According to Gallileo the aim of science is
not opening a door to infinite wisdom but
putting limits on infinite error.
Unitas... where certainty is attained by
numerical data Libertas... where doubt
prevails and figures cannot decide Caritas...
means respect and appreciation in patient care





and because The overestimation of what
medical science is capable of, has created a
dangerous myth which, as our experience reveals,
is under a taboo.



(R. A. deMelker,
University of Utrecht, 1998) Some of what
doctors do - collectively and individually - has
no rational basis.
(An introduction to medical
audit in GP, University of Liverpool, 1996)

The revolution in medical science is
still not realized but obligatory crisis
preceding it, is fully established. (Dr G.
Achterberg, Schweizerische Arztezeitung, 1998)
The application of scientifically based
guidelines is no medicine of the cookery book
kind, with ready-made answers for practice, but
requires integration of scientific knowledge with
clinical experience /R. A. Melker/
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THE MISSION...GP/FD - The art of talking with
the people
Vesalius
Pasteur
Mendel
Our modern doctrine is a contrivance of the
word-catchers the art of talking rather
than the art of healing!



(Thomas Sydenham, THE WORKS, vol. I)
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???????...GENERAL PRACTICE - Position in
medicine
The SPECIAL AND UNIQUE POSITION OF
GENERAL PRACTICE BETWEEN THE IVORY TOWER
OF GREAT MEDICINE AND DAILY LIFE
NEEDS AND DIFFICULTIES OF GRASS-ROOTS is


Who are we, where are we from and where
are we going ?"

• WITH A RELATIVELY INTELLIGIBLE PHILOSOPHY
• WITH A NEW STRATEGY OF CONSULTATION
• WITH A NEW SCIENTIFIC MODEL OF THE
  DOCTORS ROLE
• WITH A NEW PARADIGM OF HEALTH CARE
• WITH A MISSION REALLY HUMANE AND
  INTELLIGENT,
• WHICH HAS NEVER TOUCHED
  TRADITIONAL MEDICAL EDUCATION YET
• WITH A GREAT DECLARATION OF INDEPENDENCE,
  CLAIMING FOR GPs
• POLITICO - ECONOMICAL INDEPENDENCE
• that means a liberal profession, a conditio
  sine qua non for personal doctoring
• MEDICO - SCIENTIFIC INDEPENDENCE
• that means a cool distance to the
  biomedical establishment,
• necessary to refine The Real Thing, which
  is not Coca-Cola, but a
• GENERAL PRACTICE AS A SPECIALTY WITH ITS
  OWN SPECIFIC WEIGHT,
• ITS OWN CORE CONTENT, ITS OWN PECULIAR SKILLS,
  ITS OWN PROUD IDENTITY.
• 
  
  
  
  
  R.A.deMelker

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IF YOU WANT TO BE A G P (After Rudyard
Kipling)
HELPING EACH PATIENT REACH THE HIGHEST
QUALITY OF LIFE AND HEALTH !

• IF A FELLOW - COUNTRYMAN
• WOULD CURE AND CARE FOR MEN, YET
• NEVER FORGET "THE SICK ONE IS A
  PERSONALITY
• IF THE FIRST APPEAL FOR HELP SCATTERED AS
  A PUZZLE
• IN CONFIDENCE, TRUST AND HOPE -
• WITH DEVOTION IS ADDRESSED TO ONE'S
  OWN DOCTOR
• IF THIS DOCTOR IS ABLE TO UNDERSTAND
• THE PAIN OF BODY AND SOUL,
• AND FIRST WILL GRASP THE PROBLEM, HERE
  AND NOW
• IF HE SHOULD DECIDE WHY AND HOW, SOMETIMES
• THE SUFFERER WITH ANOTHER KIN-SOUL TO
  SHELTER -
• YET NEVER LEAVING HIM WHILE HE IS
  ALIVE
• IF BY THE SAME ZEAL, WITH THE SAME
  SKILLS,
• AT THE SAME WARM BREATH -
• MOTHER, FATHER AND THE WHOLE TRIBE
  WILL COMFORT
• IF - BY CHANGING THEIR TINY WORLD -
• GENTLY WILL PUT GUILT AND FEAR ASIDE
• IF HE ALWAYS KEEPS CALM AND CONCERNED ,
• AND TURNS UP - THROUGH STORM OR IN
  THE HEAT,

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10 YEARS GENERAL MEDICINE
MEDICAL UNIVERSITY PLEVEN, BULGARIA FACULTY
OF PUBLIC HEALTH