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FAMILY MEDICINE – NEW SPECIALIZATION – MOST NEED FOR DEVELOPING COUNTRIES

Dr.S.ABBAS ALI
MD, DFM, DNB(FAM.MED)
MNAMS (Family Medicine)
FCGP, MCCP (Cardiology)
PGDHSc(Ultrasonography)
PGDHSc(Echocardiogram

Family medicine is defined as a field of specialization which provide comprehensive and holistic health care services centered on the family as the unit – from first contact to the ongoing care of chronic problems including promotive, preventive, curative and rehabilitative health care services. Family medicine is different from Community medicine. Community medicine specialists deals with populations and try to measure the needs of populations both sick and well and engaged in services to meet those needs. They do not provide comprehensive health services to individuals or Family. Family medicine is horizontal speciality like internal medicine and pediatrics, shares of large areas of content with other clinical disciplines. Family medicine is different from Internal medicine. The specialty of internal medicine is comprised of physicians trained in adult medicine who provide the majority of health care to adults in the hospital or clinic. The internist do not trained in maternity and child care and they do not treat children and neonates. In short, Family medicine specilist is specialist in internal medicine, paediatrics, Obs&gynae, surgery and community medicine. single specialization for all the problems of family and needed for developing nations.
Medicine has moved from organism to organ, from organ to cell and from cell to molecular properties. The vast increase of medical knowledge during the 20th century has contributed to increasing complexity of specialization with in the medical profession. There are at present 20 recognized specialties and many more subspecialties. Some specialties have emerged based on clearly defined skills such as surgery, radiology, and anesthesia, some based on parts of the body such as ENT ophthalmology, cardiology and gynecology and some based on particular age group such as pediatrics, geriatrics and obstetrics. Again in each speciality, there has been a growth of subspecialties as for example, neonatology, perinatology, pediatric cardiology, pediatric neurology, and pediatric surgery – all in pediatrics. A super specialist or sub specialist is one who learns more about less and less. He is concerned with particular organ or part of the body. The specialization and micro specialization contributed the mushrooming growth of large luxurious super speciality hospital. No doubt, specialization raised the standards of medical care but it favors high cost, low coverage, and elite oriented health services.
Despite spectacular advances in medical advances and massive expenditure, the death rates and life expectancy in the developed countries have remained unchanged. So the developed and developing countries needed a specialization which focuses on organism or specialization in general practice which give comprehensive and personalized health care. In 1966 two reports namely Mills commission report, Willard committee reporting United States made similar recommendations. In 1971 the American academy of general practice which began in 1947 changed its name to American academy of Family physicians. The emergence of new speciality family medicine has been hailed as a rediscovery of the human, social and cultural aspects of health and disease.
The American Academy of Family Practice (AAFP) defines family medicine as a “medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity.” Family medicine aims to provide initial, continuing and comprehensive care, while centering this process on the patient-physician relationship in the context of the family. These physicians emphasize disease prevention and health promotion, and when referral is indicated, the physician remains the coordinator of patient care.
In Family medicine referral system is not just sending patients to super speciality hospital or sub specialists but they consider it as two way exchange of information by referring to particular sub specialist and follow-up care of those who referred in consultation with sub specialist. It will ensure continuity of care and inspire confidence of the patients. The family doctor serves as a patient advocate in dealings with sub-specialists, third-party payers, employers and others. Ideally, this leads to decreased disintegration of patient care in inpatient settings, higher patient satisfaction, and increased cost-effectiveness.
National board of examinations, New Delhi requirements of family medicine specialization include after passing primary, 3 year mandatory training in the recognized centers of NBE, acceptance of thesis, pass in final examination. The training programmes address a large breadth of topics; general medicine, surgery, pediatrics, maternity care, gynecology, care of the surgical patient, musculoskeletal and sports medicine, emergency care, mental health, community medicine, skin, diagnostic imaging and nuclear medicine, and management of health systems

ALCOHOLISM, ITS PROBLEMS AND ROLE OF FAMILY PHYSICIAN

Dr.S.ABBAS ALI
MD, DFM, DNB (FAM.MED)
MNAMS (Family Medicine)
FCGP, MCCP (Cardiology)
PGDHSc (Ultrasonography)
PGDHSc (Echocardiogram)


Alcoholism is usually defined by the behavioral patterns and consequences of alcohol intake, not on the basis of the amount of alcohol intake. Abuse is defined by a repetitive pattern of drinking alcohol that has adverse effects on social, family, occupational, or health status. Dependence is defined by alcohol-seeking behavior, despite its adverse effects. Many alcoholics demonstrate both dependence and abuse, and dependence is considered the more serious and advanced form of alcoholism. A clinically helpful approach to diagnosis of alcohol dependence and abuse is the use of the CAGE or TWEAK questionnaire, which is recommended in all medical history-taking

CAGE Questions


Acronym Question
C Have you ever felt you ought to C ut down on your drinking?
A Have people Annoyed you by criticizing your drinking?
G Have you ever felt Guilty or bad about your drinking?
E Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?


TWEAK QUESTIONNAIRE

Acronym Questions points
T Have you an increased tolerance to alcohol 2
W Did you worry about your drinking 2
E have you ever had alcohol as an eye opener in the morning 2
A Do you ever get amnesia after drinking alcohol 2
K (C) Have you ever felt c(k)ut down on your drinking 2

A score of more than 2 suggests an alcohol problem. It may be more sensitive than the CAGE questionnaire in some populations (eg.pregnant women)
1. EPIDEMIOLOGY
World wide an estimated 2.3 million people die from alcohol related causes. This is 3.7% of all deaths. 6.1% among men and 1.1% among women. In India survey showed that around 20-30% of adult males and 5% of adult females use alcohol. While alcohol is used traditionally by men, its use by women is now on the increase. Over the past 30-40 years increasing percentages of young people have started to drink alcoholic beverages. Their alcohol consumption has increased in quantity and frequency and the age at which drinking starts has declined. This situation is disturbing because the young people concerned may run a greater risk of alcoholic problems in later life and also, in the short term because of increased rates of drunkenness and involvement in road accidents.
2. PROBLEMS OF DRINKING TOO MUCH ALCOHOL
Liver and body can usually cope with drinking a small amount of alcohol. Indeed, drinking a small amount of alcohol (1-2 units per day) may help to prevent heart disease and stroke. Heavy drinking has an increased risk of developing disturbance in function of many organs and in the long run organ damage with irreversible serious complications.

2.1. Liver problems: Drinking too much alcohol can lead to three types of liver conditions - fatty liver, hepatitis, and cirrhosis. Any, or all, of these conditions can occur at the same time in the same person.
2.1.1. Fatty liver
Drinking a large amount of alcohol, even for only a few days, can lead to a build-up of fats in the liver. This is called alcoholic fatty liver disease, and it's the first stage of ARLD. Fatty liver disease is not usually serious and rarely causes any symptoms but it is an important warning sign that you are drinking at a level harmful to your health. 90-100% of heavy drinkers have alcoholic fatty liver disease and it is reversible on abstinence of alcohol. If drinking of alcohol is continuous one in four drinkers with fatty liver disease will develop alcoholic hepatitis and one in five drinkers with fatty liver disease will develop cirrhosis.
HOW TO DIAGNOSE FATTY LIVER: Mild increase in Liver profile and increased serum triglyceride levels. Ultrasound of abdomen shows increased echogenicity of liver.
2.1.2. ALCOHOLIC HEPATITIS:
 Hepatitis means inflammation of the liver. The inflammation can range from mild to severe. Alcoholic hepatitis is an acute form of alcohol-induced liver injury that occurs with the consumption of a large quantity of alcohol over a prolonged period of time; it encompasses a spectrum of severity ranging from asymptomatic derangement of biochemistries to fulminant liver failure and death
 Mild hepatitis may not cause any symptoms. The only indication of inflammation may be an abnormal level of liver enzymes in the blood, which can be detected by a blood test. However, in some cases the hepatitis becomes persistent (chronic), which can gradually damage the liver and eventually cause cirrhosis.
 A more severe hepatitis tends to cause symptoms such as feeling sick, jaundice (yellowing of the skin, caused by a high level of bilirubin - a chemical normally metabolized in the liver), generally feeling unwell and, sometimes, pain over the liver.
 A very severe bout of alcoholic hepatitis can quickly lead to liver failure. This can cause deep jaundice, blood clotting problems, confusion, coma, and bleeding into the guts, and is often fatal.
 The main treatment for alcoholic hepatitis is to provide adequate nutrition (this sometimes involves passing liquid feeds through a tube in the stomach) and steroids.
2.1.3. CIRRHOSIS: Cirrhosis is a condition where normal liver tissue is replaced by scar tissue (fibrosis). The scarring tends to be a gradual process. The scar tissue affects the normal structure and regrowth of liver cells. Liver cells become damaged and die as scar tissue gradually develops. So, the liver gradually loses its ability to function well. The scar tissue can also affect the blood flow through the liver which can cause back pressure in the blood vessels which bring blood to the liver. About 1 in 10 heavy drinkers will eventually develop cirrhosis. It tends to occur after 10 or more years of heavy drinking. The scarring and damage of cirrhosis is usually permanent. Early cirrhosis is compensated cirrhosis. Early symptoms of liver disease can include:
• fatigue
• nausea
• vomiting
• diarrhoea
• abdominal pains
Later stage cirrhosis (decompensated cirrhosis) symptoms are more serious – They can include:
• jaundice (yellow skin)
• vomiting blood
• fatigue
• weakness, loss of appetite
• itching
• easy bruising
• swelling of the legs ankles, or abdomen (ascitis)
• liver cancer
• bleeding in the gut
• increased sensitivity to alcohol and drugs, both medical and recreational (because the liver cannot process them)
In cirrhosis, complete abstinence of alcohol is essential to prevent more serious complications of liver failure. The treatment option of cirrhosis is Liver transplantation.
2.2.GI tract and stomach; obesity (alcohol has many calories)diarrhea, gastric erosions, peptic ulcer, varices (which results in haematemesis) carcinoma, oral mucosal lesions and pancreatitis (both acute and chronic)
2.3.CENTRAL NERVOUS SYSTEM: Stroke (CVA), poor memory (Problems with thinking, memory, mood) poor cognition, faintness and light headedness, cortical atrophy, retro bulbar neuropathy, fits, falls, wide based gait, neuropathy(numbness in legs and feet) , confabulation, korsokoff psychosis, wernicke’s encephalopathy. Mental health problems, including depression and anxiety, Jealousy, temper tantrums, vagrancy, auditory hallucinations, and paranoid delusions. Unintentional injuries, suicides, homicides, total social damage which includes family disorganization, domestic violence, wife battering, crime and loss of productivity.
2.4. Heart: arrhythmias, Hypertension, cardiomyopathy, sudden death in binge drinkers (Holiday heart syndrome)
2.5. GENITOURINARY SYSTEM: Sexual difficulties such as impotence, testicular atrophy, with shrinkage of seminiferous tubules, loss of sperm cells,
2.6. HAEMOPOITIC SYSTEM: leucopenia (decreased WBC) thrombocytopenia (decreased platelets), anemia, ↑MCV, sideroblastic anemia
2.7. VITAMIN DEFICIENCIES: alcoholism associated Vitamin B complex (thiamine) and Folate deficiency,
2.8. INCREASED CANCER RISK: Cancer is the second leading cause of death in alcoholics after cardiovascular disease. Common sites include head and neck, mouth, pharynx, larynx, oesophagus, cardia of stomach, colon, breast, Liver and pancreas.
2.9. Accidents - drinking alcohol is associated with a much increased risk of accidents. In a study in Bangalore, nearly 28% of traffic injuries were found directly attributable to alcohol.
2.10. High risk sexual behavior: Sexually transmitted diseases including HIV/AIDS, Hepatitis B and C: Alcohol use is considered a risk factor for high risk sexual behavior leading to STD including HIV/AIDS, Hepatitis B & C
2.11. Infections: pneumonia and tuberculosis are more common in alcoholics
2.12. FETAL ALCOHOL SYNDROME: Damage to an unborn baby in pregnant women. The baby has low IQ, short palpabral fissure, absent philtrum and small eyes.
2.13. ALCOHOL WITHDRAWAL: It starts after 10 to 72 hours after last drink characterized hypotension (↓BP) rapid pulse, tremor, confusion, fits, hallucinations (delirium tremens) may be visual or tactile eg. Animals are crawling on the skin. The alcohol withdrawal patients should be admitted in hospital
• give IV fluids and stabilize BP & pulse
• 25%Dextrose
• Inj. Thiamine
• Chlordiazapoxide 10-50mg 6 hourly etc.,
3. MANAGEMENT
3.1. The family physician should consider every consultation is an opportunity to detect early-warning signs that prevent illness and disease. Sensible, timely and appropriate interventions can help make people aware of the potential risks they are taking. Health promotion is not simply risk avoidance, rather than active encouragement of individuals to increase control over bad habits which are detrimental to health, to attain their best possible level of well being.
3.2. Opportunistic health promotion and disease prevention is defined as “an advice made more effective by being directly linked to the content of the preceding consultation”. For example, advice to stop alcoholism is proportionately more powerful when it is linked to an episode of acute vomiting, abdominal pain etc. Prevention: prevention is always better than cure because it reduces undue suffering from diseases. Promotion of health, preservation of health and restoration of health when it is impaired. Nowadays, however, the majority of mortality and disabling illness accounted for by ischemic heart disease, stroke, cancer, and chronic lung disease. These are principally affected by life styles and habits of individuals, alcoholism, smoking, diet and exercise. Consequently the role of the physicians has become more important and he/she must communicate this information more effectively to his/her patients. Helping patients to take responsibility of their own health must be the fundamental feature of opportunistic health promotion and disease prevention
3.3. Identity high risk factors: such as smoking, tobacco chewing, high risk sexual behaviour, physical inactivity, history of premature death or CHD, stress factors, contraceptive use and failure or inability to obtain preventive health services. If found provide promotive and preventive measures.
3.4. Identify co-morbid conditions: like Diabetes, obesity, hyperlipidaemia, hypertension. If found specific intervention and necessity of treatment should be carried out to control these conditions for preventing organ damage.
3.5. If alcoholic having liver problems, alcohol is contraindicated. The other conditions where alcohol contraindicated are pregnancy, carcinoid, peptic ulcer, and serious reactions will occur with drugs (antihistamines, metronidazole)
3.6. Psychological assessment of motivation: the patient should be psychologically motivated. Treating established alcoholic may be rewarding particularly if they want to change their life style. If so family therapy, group therapy or self help may be useful in self initiated and determined alcoholic. The family members and friends should encourage the alcoholic will to quit. Give and maintain follow up and encourage.
3.7. If patient is alcoholic with no evidence of liver disease advise measures for preventing alcohol-related liver disease. The most effective way to prevent ARLD is to stop drinking alcohol, or stick to the recommended daily limits and have at least two alcohol-free days a week.
3.8. .The recommended limits of alcohol consumption are:
 Men should not regularly drink more than 3 units of alcohol a day.
 Women should not regularly drink more than 2 units a day. One unit of alcohol is 10 ml (1 cl) by volume, or 8 g by weight, of pure alcohol. For example: One unit of alcohol is about equal to:
 half a pint of ordinary strength beer or cider (3-4% alcohol by volume); or
 a small pub measure (25 ml) of spirits (40% alcohol by volume);
 A standard pub measure (50 ml) of fortified wine such as sherry or port (20% alcohol by volume).
 There are one and a half units of alcohol in a small glass (125 ml) of ordinary strength wine (12% alcohol by volume) or a standard pub measure (35 ml) of spirits (40% alcohol by volume).
 But remember, many wines and beers are stronger than the more traditional ordinary strengths. A more accurate way of calculating units is as follows. The percentage alcohol by volume (% abv) of a drink equals the number of units in o in one litre of that drink. For example:
 Strong beer at 6% abv has six units in one litre. If you drink half a litre (500 ml) - just under a pint - then you have had three units.
 Wine at 14% abv has 14 units in one litre. If you drink a quarter of a litre (250 ml) - two small glasses - then you have had three and a half units.
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