The principle of context in family medicine.
The discipline of family medicine has evolved to fulfil a need for patient-centred care based on a more holistic biopsychosocial model rather than a disease-based biomedical model. (1), (2) Many patients presenting to their physicians have no organic pathology and present with physical symptoms that have primarily an emotional or psychosocial basis. (3)
To address these concerns adequately, Fehrsen and Henbest have developed a patient-centred clinical method, i.e. the Three Stage Assessment, (4) encompassing the clinical (biomedical), individual (feelings, fears, concerns, beliefs, expectations) and contextual (micro- and macro-environmental) assessments, which are inextricably linked in terms of fully understanding the patient's illness experience. It ensures a holistic assessment of the patient and is a paradigm shift away from the traditional biomedical assessment.
This clinical method is particularly relevant to primary care where the presentation is often one of many symptoms and few clinical signs, either because of the early stage of the disease or because there is no organic pathology. (2) As many as 50 - 75% of patients utilising primary care clinics have a psychosocial precipitant as opposed to biomedical problems as the main cause of their visit. (3)
No patient exists in a vacuum. Every patient exists in a hierarchy of systems. The patient is at the lowest level of the supra-system and their state of health is influenced by many personal, interpersonal and cultural issues. Any dysfunction in this system is expressed as an illness presentation, e.g. chronic tension headaches, insomnia, relationship break-down, etc. (2) Sub-systems devolve to intrinsic dynamic state dysfunction of the neuro-endocrine immune system, organ systems, tissues and cells, to molecules (1), (2) as an expression of a disease process.
McWhinney's Principles of Family Medicine state that: (1) 'The family physician seeks to understand the context of the illness. "To understand a thing rightly, we need to see it both out of its environment and in it, and to have acquaintance with the range of its variations, " wrote William James. Many illnesses cannot be fully understood unless they are seen in their personal, family, and social context. When a patient is admitted to hospital, much of the context of the illness is removed or obscured. Attention seems to be focused on the foreground rather than the background, often resulting in a limited picture of the illness.'
The following case presentation illustrates these points explicitly in terms of the patient's context being the key to whole-person wellness.
DR is a 16-year-old female patient admitted to the high care unit of a district hospital for emergency management for diabetic ketoacidosis. Standard treatment guidelines were followed, and on day 3 the patient was well enough to be transferred to the general female medical ward. No precipitating cause for the metabolic decompensation could be found, such as a chest or pelvic infection. The patient claimed that she was compliant with her diet and medication. On review of the out-patient file it was noted that this was the patient's fifth admission to the high care unit for diabetic ketoacidosis within 6 months.
The patient was restarted on insulin therapy, fluids and dietary modification. Despite our best efforts her blood sugar was difficult to control while she was on a strict diet in the ward. Then the staff reported that the patient was seen at the tuck-shop of the hospital eating half a loaf of bread and drinking Coke.
We were surprised by this apparent incongruent behaviour and actively sought to explore the context of the patient's presentation.
This was done by establishing a good doctor-patient-nurse relationship based on mutual trust and confidence, conducted with warmth, empathy and privacy in the side-ward and ensuring confidentiality.
The patient disclosed to us that she did not want to live and felt that her life was useless and she would be better off dead.
On further enquiry, the patient disclosed that she was raped by her married uncle a year ago following which she fell pregnant and was forced by her parents to have a TOP, which was duly performed. Her parents had also instructed her, for the sake of family harmony and for fear of community stigmatisation, not to disclose the incident to anyone, including the SAPS. Subsequently the patient performed poorly at school and dropped out, dashing her dream of studying towards a degree, which would have the benefit of giving her greater lifestyle choices than her family currently enjoy. She later tested positive for HIV, which she knew was the direct result of the rape as she was sexually inactive.
Furthermore, her uncle continues to taunt and threaten her with rape, because of the perceived indifference and apathy from her parents, and which she now finds unbearable.
Death for her was the only way out of her torment.
The patient was reassured and intensively counselled by the social worker and psychologist. The parents were interviewed and informed of their duties and obligation under law and the impending criminal implications against them should they not report the crime of rape. They were also reminded of our mandatory obligation under the Children's Act to report the crime of rape to the SAPS. They had agreed to lay charges against the patient's uncle.
The patient clearly had post-traumatic stress disorder with major depressive symptoms and a process of intensive psychotherapy was commenced.
She was also counselled regarding her HIV status and was reminded that this was a chronic manageable condition such as hypertension and diabetes. She is currently awaiting the results of her CD4 count. The patient was moved to a place of safety and schooling was to be restarted.
The above case scenario succinctly put into perspective McWhinney's comment on the exceptional potential of the consultation in that: 'All communication necessitates context ... without context there is no meaning.'(1)
References available at www.cmej.org.za
K Naidoo, MB BCh, MMed FamMed, LLM
Principal Specialist, Department of Family
Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban
Correspondence to: K Naidoo (email@example.com)
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|Title Annotation:||CASE REPORT|
|Publication:||CME: Your SA Journal of CPD|
|Date:||Oct 1, 2011|
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