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6 WEEKEND WSH
FOR COMMUNITY FD IN FM IN-SERVICE
TRAINING
6 WEEKEND WSH
FOR COMMUNITY FD IN FM IN-SERVICE
TRAINING
ผศ.พญ.สายพ�ณ หั�ตถี�รั�ตน์�
ภาควิ�ชาเวิชศาสตรั�ครัอบครั�วิ คณะแพทยศาสตรั�
รัพ.รัามาธิ�บดี�
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1st WEEKEND
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Principles of FM in Thailand
1.1. Doctor-Patient RelationshipDoctor-Patient Relationship2.2. Comprehensive Clinical primary Comprehensive Clinical primary
care to all family memberscare to all family members3.3. Community-oriented/population-Community-oriented/population-
oriented careoriented care
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Type of Medical
Care
Primary CarePrimary Care1. First Contact2. Continuing Care3. Comprehensive Care4. Coordinating Care
Secondary Care1. Short stay in hospital 2. MD consulting
Tertiary Care1. Uncommon
Disease2. Need intensive &
close monitoring3. Disease
Specialists
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Ecology of Medical Care
1000
750
250
951
Adult population
Age 16+ yrs
Illness or injury a month
Consulting MD in PC
a month
Admitted a month
Referred TC a month
Referred medical center a monthWhite KL. NEJM 1961;265(18):885-
892
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Hierarchy of natural systems
Engel G. The clinical application of the biopsychosocial model. Am J Psychiatr 1980;137:535-44
Biosphere
Society-Nation Culture-Subculture Community
Family Two-person Person
Nervous system Organ system
Tissues Cells
Organelles Molecules
Atoms Subatomic particles
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Holistic Framework
Person• Who, Life cycle• Development• Family of Origin
Illness
Disease
Family•Family System•Family Life cycle•Family Stress•Family Coping•Family Resource•Impact on Health
Community•Pt.& Fam Role•Resource•HSS•Work•School•Culture•Religion
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ConsciousnesConsciousnesss
Unconsciousness
Behaviour
Feeling
Perception
Expectation
Yearning
Self
Cognitive-Behaviour Linkage
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Health Belief Model
1.ฉั�น์อยากดี"แล
ส$ขภาพต�วิเอง
4. ม�น์จะค$(มไหัมถี(าจะ
เปล�+ยน์แปลง
3. ฉั�น์จะแย,แน์, ถี(าป-วิย
2. ฉั�น์ม�โอกาสจะ
ป-วิย
5. เออ! ไอ(คน์น์�/น์ม�น์ย�ง
เป0น์เลย
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Locus of Control
1. Internal controller2. External controller3. Powerful other
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Stages of Behaviour Stages of Behaviour ChangeChange
Precontemplation
Contemplation
Preparation
ACTIOACTIONN
Maintenance
( From Prochaska JO. Am Psychol 1992;47(9):1102-1114 )
Relap
s
e
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Difficult Pt.
Neg. MD’s perceptiontowards Pt.
Difficult MD-Pt.
Relationship
Difficult MD
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Learning about "Difficult" Pt. is
Learning about "yourselves"
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จ�ตบ1าบ�ดี ค2ออะไรัPsychotherapy = editing the
story
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ค$ณสมบ�ต�น์�กจ�ตบ1าบ�ดีท�+เก,งTrust
Continuity
Support & comfort
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2nd WEEKEND
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Family SystemFamily System
Whole system
Organ
Hormone
Function
Homeostasis
Hierarchy
Remote pathogen
Change over time (Morphogenesis)
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Family Health AssessmentFamily Health Assessment
Stress in Family : Family tree: Family life cycle: Time Flow Family
Chart Coping Resources Impact on health
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Couple Development Couple Development CycleCycle
Romance Unmet
expectation
ConflictCommunicate
Remorse
Individual
Individual
Family of Origin
Society Culture
Society Culture
Family of Origin
Stage 2: In-Laws
Family
Stage 1: Mutual
Relationship
Stage 3: Parenting
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Family-oriented pregnancy care
Family of pregnancy and childbirth = developmental stage of family
Critical period of family transition“Triangle”: Parent – Couple –
GrandparentRisk : alliance , coalitionInfertile & Adoption
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Family-oriented pregnancy Family-oriented pregnancy carecare
First First TrimesterTrimester Third Third
TrimesterTrimester
Second Second TrimesterTrimester
LaborLabor
PostpartuPostpartumm
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Family-oriented child care
พ,อแม,เข(มพ,อแม,เข(มแข3งแข3ง
พ,อแม,ม�พ,อแม,ม�ป4ญหัาป4ญหัา
เดี3กเดี3กแข3งแข3งแรังแรัง
เดี3กเดี3กป-วิยป-วิย
เดี3กแข3งแรัง
พ,อแม,เข(มแข3ง
เดี3กป-วิยพ,อแม,เข(ม
แข3ง
เดี3กแข3งแรัง
พ,อแม,ม�ป4ญหัา
เดี3กป-วิยพ,อแม,ม�ป4ญหัา
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Special Adolescent Special Adolescent healthhealth
• Confidentiality• Care for Parents & Adolescent• Identity• School performance• Peer group• Couple/ intimacy/ sexual health• Addiction /accident
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3rd WEEKEND
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ส$ขภาพวิ�ยกลางคน์1 .ส$ขภาพรัะดี�บบ$คคล2. ส$ขภาพรัะดี�บค",
ครัอง3. ส$ขภาพบ$ตรั4. ส$ขภาพพ,อแม,ท�+ชรัา
40 + yrs
20 + yrs
60 + yrs
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ส$ขภาพผ"(ป-วิยส"งอาย$ป4ญหัาส$ขภาพหัลาก
หัลายรั,างกายเส2+อมสภาพปรัาบยาไม,หัมดีไปอาการัทางกายกลาย
เป0น์ทางจ�ตอาการัวิ�ปรั�ตผ�ดีจาก
หัน์$,มสาวิ
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ส$ขภาพผ"(ป-วิยดี(วิยโรัคท�+หัมดีหัวิ�ง
Symptom
• Disease
• Distress
• Discomfort
• Dysfunction
Dx
Disease Rx Palliative Rx
DeathDying
Person with illness
Family
Caregiver
Bereavement
Active Total Care for best QOL
[pt.+family]
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WWF of the dying
• Approach as individual• Explore relationship• Detect “Conspiracy of Silence”• Empathy their loss/help• Contact number• Family meeting
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ล�กษณะพ�เศษของโรัคเรั2/อรั�ง เป0น์ข,าวิรั(ายเส�ยหัายถีาวิรัดี1าเน์�น์โรัคไม,หัย$ดีน์�+งทรั$ดีดี�+งลงเรั2+อยๆม�ช�วิ�ตข7/น์ลง เดี�8ยวิทรังเดี�8ยวิ
ทรั$ดี
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กลไกของบ(าน์เม2+อเดี3กป-วิยเรั2/อรั�ง
Sick Kid
Demanding KidParent Guilty
Parent Overindulgence
Manipulative sibling
Child’s Grief Parental Grief
ExacerbateillnessMarital
Conflict
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โรัคเรั2/อรั�ง ค2อ ต�วิเรัาท�+ไม,เท�+ยง
ต(องเรั�ยน์รั"(ท�+จะอย",ก�บม�น์อย,างม�ควิามส$ข เหัม2อน์
น์�ยายท�+อ,าน์ค(างไวิ( ย�งไม,ถี7งตอน์จบ
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Behaviours: DefinitionBehaviours: Definition
Action 1
Action 2
Action 3Action 4
Action 5
Strong MotivationStrong Motivation
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continuum of Alcohol use
No/Low Risk
At Risk
Mild Moderate
Severe
Alcohol AbusePast 12 mos :
A.Role impairB.Hazardous useC.Recur legal problemsD. Social impairAlc DependenceToleranceWithdrawalCAGE +
Risky DrinkingCurrent drinkingNo consequence
Problem Drinking
ExperienceConsequence
of Drinking
Safe Drinking
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Violence WheelViolence Wheel : Type of Abuse
POWER
&
CONTROL
VIOLENCE
VIOLENCE
THREATS
INTIMIDATION
EMOTIONAL ABUSE
ECONOMIC ABUSE
MALE PRIVILEGE
USING CHILDREN
MINIMIZING DENYING BLAMING
ISOLATION
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Cycle of Domestic ViolenceCycle of Domestic Violence
Honeymoon
Tension Build
Up
Violence /
Abuse
Remorse
Wooing
Explosion
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Character of MD health
“3D + 4S” Delusion Denial Delay Self-Ix, -Dx, -Rx, -
ReferralIntellectualization or
Rationalization
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4th WEEKEND
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ถี(าเรัาย,อโลกใหั(เหัล2อปรัะชากรั 100 คน์ 57 Asians
EEEEEEEEE21 14Western: EEEEE &
south EEEEEEEE8
-70 nonwhi te
30white -70 non Christian
30 Christian
89 heterosexual 11 homosexual
EEEEEE52 48 male
• EEEEEEE 6 59% of
the entire’ wealth• E EE EEEE US
80 live in substandardEEEEEEE
70 unable to read 50 suffer from
malnutrition EEEEEEEE EEEE 3
E EEEEEEEE E 1 near death 1 near birth 1would own
a computer
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Types : Home Visits (HV)
1. Illness home visits2. Palliative home visits3. Assessment home visits4. Post-Hospitalization home visits
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Home Visit Assessment:IN HOME SSS I Immobility N Nutrition H Home environment O Other people M Medications E Examination S Safety S Spiritual health S Home health care services
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5th WEEKEND
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Learning styles
Accommodator
จ�ดีใหั( Diverger
เคารัพใน์ควิามแตกต,าง
Convergerน์1ามาบรัรัจบก�น์ ปรัะมวิลผล
Assimilator
ท1าใหั(กลมกล2น์
ใจ(Feeling)
หั�วิ(Thinking
)
ดี"(Watching
)
ท1า(Doing)
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Adult learning [Andragogy]Learner-focused education
Helping adult to learn
ไม,ใช, neglect
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10-min consultation in OPD
DiscussionOne minute
PRESENTATIONSix minutes
QUESTIONINGThree minutes
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One-Minute Preceptor One-Minute Preceptor (OMP)(OMP) ModelModel
Get a commitment (สรั(างพ�น์ธิะส�ญญา) Probe for supporting evidence
(แสวิงหัาหัล�กฐาน์) Provide positive feedback (ท1าถี"ก
ยกย,อง) Teach general rules (สอน์หัล�กการั
ส1าค�ญ) Correct mistakes (ท1าผ�ดีแก(ไข)
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Evaluation process
studen
tte
acher
progra
mformative
summative
normcriterion
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Social discrimination between competent/incompetent student
A B
C DTest result
Pass
Fail
Incompetent
Competent Truth
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The competence pyramidMiller’s PyramidDoes
Shows how
Knows how
Knows
Action
Performance
Competence
Knowledge
Pro
fessio
nal A
uth
en
ticit
y
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Feedback ท�+ดี�
Specific performance , not generalization
Should be “first hand” information
หัย$ดีและฟั4ง เม2+อผ"(รั�บ feedback ไม,ยอมรั�บ
กรัะช�บ ไม,ย2ดีเย2/อ ซ้ำ1/าซ้ำาก
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6th WEEKEND
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Evidence-based medicine (EBM)การัเอา Clinical experience + External evidence อย,างม�หัล�กการั เพ2+อต�ดีส�น์ใจทางคล�น์�กอย,างม�ค$ณภาพเพ�+มข7/น์
EBM ไม,ใช,พรัะเจ(า เป0น์แค,ต�วิช,วิยใน์การัต�ดีส�น์ใจ
ข(อม"ลมากมาย อย,าเช2+อเพ�ยงเพรัาะเขาบอกมาต�/งค1าถีามเป0น์(PICO) หัา evidence ใหั(เจอ
ค�ดีวิ�เครัาะหั� แล(วิปรัะย$กต�ใช(
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EBM : Diagnosis Study validity : Diagnostic
uncertainty, compared with gold standard test
Result : 2x2 table, large LR
Apply : my setting/my patient
BENEFIT >>> harm
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EBM : ScreeningDiagnostic test validity improve QOL/survivalTime/money consuming lifelong carefreq/severity of diseaseBENEFIT >>> harm
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EBM : Therapy Study validity: Randomized, conceal,
ITT, triple blinded, follow up rate
Result : ARR, NNT, side effects, P value, 95%CI
Application : POEM/DOE
BENEFIT >>> harm ‘Watchful waiting = Rx’
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EBM : Guidelines Study validity: Who produce, conflict
in panel, comprehensive search, funding
Result : include วิ�ธี�ที่��ใช้ยา /ไม่�ใช้�ยา, วิ�ธี�วิ�ดผล
Application : Killer B’s
BENEFIT >>> harm
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ข(อค�ดี อ.ปรัะเวิศ
โลกต(องม�ควิามหัลากหัลายจ7งจะอย",ไดี(ถี(าอย",รั,วิมก�น์ไดี(ดี� ก3ม�ควิามส$ขจ7งใหั(มองท�+ค$ณค,าของคน์ อย,าวิ,าก�น์
“ Power of appreciation ”
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Last Word
Not that all stress is bad,Not that all stress is bad,
Some is necessary for motivation, Some is necessary for motivation, growth & developmentgrowth & development