A Short Collection of Fables for Learning the Fundamental Principles of Family Medicine: Chapter 1. Comprehensiveness, Continuity, Contextualization and Family
It is necessary to achieve more meaningful representations of the fundamental concepts of Family Medicine, and facilitate the transfer of these to clinical practice. But, these concepts can be difficult to understand and explain, even for experienced physicians in the specialty. The fable is an adult education method that can serve to intuitively understand abstract concepts by linking them to specific situations, for facilitating their assimilation. In this way, we present the following fundamental concepts of Family Medicine through fables: Comprehensiveness, Continuity, Contextualization and Family.
Family practice, Fables, Metaphors, Comprehensiveness, Continuity, Contextualization, Family
Conceptual systematization in the specialty of Family Medicine has not matched with practice. However, it is not until that the conceptual heritage of Family Medicine, is ordered, systematised and fully clarified when it can begin the real practical work. Therefore, it is necessary to achieve more meaningful representations of the fundamental concepts of Family Medicine, and facilitate the transfer of these to clinical practice. But, these concepts can be difficult to understand and explain, even for experienced physicians in the specialty [1-5].
These fundamental concepts of family medicine are: Comprehensiveness and integrality; Continuity; Context and contextualization; Uncertainty; Complexity; Community; Patient-centered Interview; Biopsychosocial Model; Actors and resources/strengths of the patients; Family; Concept of health and disease; and Variability.
Evidence-Based Medicine, clinical trials and quantitative studies are necessary, indispensable for medical science, yes, but why not the stories, the tales and the cases? Medical science suffers from a kind of agnosia, which avoids matters related to contextual judgment, the particular, the personal, and is made exclusively abstract and statistical. But the quantitative and the Evidence-Based Medicine cannot give us an integral response . So, we will be presented these concepts by fables.
The fable is an adult education method that can serve to intuitively understand abstract concepts by linking them to specific situations, for facilitating their assimilation [7-11]. Animals, plants, and other things will be "patients" seen in consultation by the family doctor. They will be fictional stories presented as real. They will be beings or objects that are given the opportunity to think, feel and speak. In the fable it can be distinguished into two parts: one is the story itself; and the other moral. Each story seeks to make emerge, of clear form, the moral, at the end of the fable, as sobering consequence of what happened in the episode. The moral will be a fundamental concept of Family Medicine.
Family physicians do not treat diseases but take care of people. And so, a major feature of Family Medicine is that you cannot separate the physical from the psychic. It is the only medical specialty where this inevitable gap does not occur. The fables belong inseparably to both sides, and they serve precisely to save that abyss, to take us to the intersection of the objective and the subjective, the quantitative and the qualitative, the physical and the psychic, the pathology and the experience of the disease.
In this way, we present the following fundamental concepts of Family Medicine through fables: Comprehensiveness, Continuity, Contextualization and Family.
Mr. Elephant, a large animal, 40-years-old, with 5.5 tons of weight, which was wandering alone in the big African jungles, in the open steppes, or in swamps, with their huge ears, the long trunk, and their ivory tusks, needed to consult with the doctor (Figure 1). He had lost his appetite. He has drowsiness and had ceased to travel long distances in search of huge amounts of food...; he wanted not roots, or grass or fruit or bark..., had lost interest over water, previously loved, and did not enjoy with showering or filled his body of dust. He breathing worse, and his trunk had lost their ability to smell... He no longer tore the bark of trees with his trunk..., his ears did not help him to refresh.
Thus, Mr. Elephant decided to consult with several super-specialists in different medical areas. They were all true scholars in his field, and his fame had reached the border of the African savannah. Mr. Elephant was to the Polyclinic. The first consultation of Mr. Elephant was with the hepatologist and this after palpate the right upper quadrant of abdomen of the Mr. Elephant made a liver biochemistry and a Fibro scan, wall that is in his abdomen, which does not let the fruit digest. You will take cinitapride, omeprazole... and a very strict diet".
Then, Mr. Elephant was to consultation of ENT. The Doctor explored the Mr. Elephant trunk and ears, and said: "the problem is your nose-trunk which has become a snake, and his ears in a fan, so you cannot smell, or remove the flies with his trunk, or that your ears make the appropriate thermoregulatory functions. I will prescribe cortisone and antibiotics".
In dental consultation, after exploring the Mr. Elephant tusks, the Dentist said: "the problem is his fangs that have become a spear, and thus you cannot boot the crust.... I there will be extracted them..., although it is prohibited...".
In consultation with neurologist, after that this specialist explored the head, made CT, MRI, EEG, and psychometric tests... he said: "although the tests are normal for their age, it is clear that this is a case of memory loss. You need galantamine, or rivastigmine or donepezil. You better take them all together, given their size!"
In the consultation with the orthopedist, the Doctor explored the leg of Mr. Elephant, and after making an RX, a soft tissue ultrasound and MRI, said: "this is your legs have become trunks of a tree, so you cannot walk on the tips of his fingers. You need an orthotic, using batons, and nonsteroidal anti-inflammatory drugs... Oh, and I will send you to rehab!"
Finally, in the consultation of the urologist, the Doctor said to Mr. Elephant, after making an urine analysis, PSA and abdominal ultrasound: "sorry, but your discomfort or illness is not in my field, but I am going to prescribe tamsulosin, as treatment of prevention of your future benign prostatic hypertrophy".
"Medicine is a matter that concerns the body, which consists of parts and components that are studied separately and are different entities. The mind is a separate entity from the body. We reduce the problem to a biochemical phenomenon and use of a drug to act in the opposite direction... and all sorted out!" they said, to the Mr. Elephant, all specialists at the same time. Mr. Elephant was confused!
After each specialist had finished their examinations and treatments, Mr. Elephant realized that these diagnoses and treatments were so different that had no confidence in their advices. So he went back to specialists, explaining what they told each other.
Upon hearing the explanations of Mr. Elephant, the different specialists were angry and went to look for the other colleagues to discuss the case. Everyone tried to convince others that he had the proper diagnosis and treatment about what was wrong in Mr. Elephant. But they soon realized that the diagnoses were so different that there was no possibility that anyone would convince the others. Specialists were also confused!
Finally, a family doctor who was watching and listening to the debate, said: "the Mr. Elephant is a huge animal, and so each diagnosis could be suitable but only for a small part... There is another way to understand holistically the problems in Mr. Elephant...".
"How is that?" specialists asked puzzled. "We can Use a model based on the holistic medical approach. The body is the shadow of the soul. Thoughts, desires and emotions of the mind affect physiological processes and behaviours. It is like conducting an orchestra, if it has a good connection there is harmony, i.e. absence of disagreement between the parties", the family doctor told them.
He added: "the allopathic or orthodox medicine is governed by the male principle: reality seen through their parts more than the whole; it emphasizes definitions, logic, order and hierarchy. It has focused on the mechanisms of the disease and the body as a machine. It has brilliantly discovered a technology to treat symptoms of body mechanics. But, the control replaces cooperation. It goes to the response to symptoms, instead of progress towards health".
"The holism and holistic medicine is influenced by the feminine: relationship and connections. Holism is a term that refers to perceive reality as a whole; nothing is separate, but every part is related to the whole. Quality is more important than quantity and reality is perceived empathic or subjectively rather than intellectually. The whole is not behaves like the sum of all their parts".
"The family doctor is committed to the person rather than with a particular body of knowledge, group of diseases or a special technique. Family doctor is available for any health problems in a person of any sex and age; its practice is not even limited to what is strictly defined as a health problem: the patient defines the problem; this means that a family doctor can never say: 'sorry, but your discomfort or illness is not in my field'. Any health problem of our patients is our field; although we can refer the patient for specialized treatment, we are responsible for the initial evaluation and coordination of care. Family doctor' work does not have a defined end point; it does not end with curing a disease, completion of a course of treatment, or the incurability of a disease; in many cases the commitment is established while the person is healthy, before they have developed any problems. Family medicine is defined in terms of relationships, what makes it unique in the major fields of clinical medicine", explained the family doctor.
"Integral or holistic understanding of patients, and therefore a holistic view of clinical cases, leads us to include most of the following aspects: Biopsychosocial data; Quantitative and qualitative data; Experience of the disease by the patient and their context; Several actors or protagonists: patient, family, specialists, relatives... community; Biographic history: projects, expectations...; Medical-patient-family-context relationship; Understanding familiar aspects (by genogram, family life cycle...) and of community aspects (resources, strengths and weaknesses, relationships...), in the diagnosis and treatment".
"It is spreading the idea that the challenge of health services is to treat pathologies one by one, but the problem is that users do not only have one illness, but several at the same time and the health problems of people are not the same that their illnesses", concluded the family doctor. With the explanation and the help of the family doctor, the 'super-specialists' that were discussing about the parts of the elephant, reconsidered their partial views, and each eventually came to understand what an elephant was.
Once upon, a camel accompanied a sick horse to visit a family doctor. Mr. Camel and Mr. Horse had agreed to make a race of 180 km in the desert... (Figure 2).
"Doctor, this is my friend Mr. Horse, which at the end of a long journey through the desert, felt faint, dizzy and fainted", said Mr. Camel. He continued: "II put him on the ground and raised his paws, and so he recovered in a few minutes... That was days ago. He is fine now, but I think you have to examine him, Doctor". "How did it happen?" asked the doctor to Mr. Horse.
"Well, Doctor..., we discussed which of the two was more constant and resistant..." said Mr. Horse. "I explained him that us camels have modified the course of history by enabling, in the first centuries of our era, trade across the Sahara desert, linking the black Africa with the Mediterranean... We, the camels, have no rival in being constant, in continually resisting, in long walks through difficult places, like the desert... Mr. Horse, said that not, that he was stronger and more constant than the camel. I said: it is the horse continuously stronger and more constant than camel? Do not!"
"I now, after the competition, I understand why in Saudi Arabia the camel is called 'The gift of God'. The horses can reach the goal before, in a race of short duration, than the camels. But, it is true that in the extreme conditions of the desert the camels are unrivalled, because they, the camels, store water, because with their lips can eat until a leather shoe, because they have four gastric cameras, and can close their eyes, ears and nostrils when there is wind with sand, and because his big feet like toppers, allow them to walk on the sand without sinking... So, I have to admit: camels can make a continuous and constant effort in difficult situations, for many days, without abandoning or surrendering... The horses we cannot do, although we run faster in short distances", said ruefully Mr. Horse.
The doctor thought: "the family doctor performing a continuity of care, for years, visiting to the same individuals and families, sometimes in extreme conditions of uncertainty… This continued attention is very difficult; It takes a lot of perseverance and resistance not to give up. This resembles the camel... The family doctor 'can arrive later to the goal' that other colleagues super-specialists who intensively use the hard technology, and it may seem that these are the 'winners', but after to make their diagnoses and treatments, they will 'disappeared' or they have a 'swoon'... They cannot follow; they do not know how to maintain a continuous care for many years. The family physician remains in the race of continuous care, with constancy and resistance, attending patients and families 'from birth to the grave'.. Family medicine is defined in terms of relationships, long-term relationships rather than in terms of diseases or technology. The continuity of relationships between family physicians and patients in their environment, even a tacit way, builds trust and creates a therapeutic healing context".
Once upon a time, five buckets of water which consulted to the family doctor. Mrs. Saucepan With-Water-at-Sea-Level-Pressure was worried about her health. "Doctor, I come to take my blood pressure... To my neighbour, who had bad the boiling point gave him the other day a thrombosis..." (Figure 3).
The doctor checked her blood pressure and after that he said, "Okay, Mrs. Saucepan With-Water-at-Sea-Level-Pressure, you have 100 ℃". Mrs. Saucepan With-Water-in-Mexico-City was worried about her pressure. "Doctor, I come to take my blood pressure... To my neighbour, who had low the boiling point, gave him the other day a syncope...".
The doctor checked her pressure, and after that he said, "Okay, Mrs. Saucepan With-Water-in-Mexico-City, you have between 90-95 ℃". "But Doctor, I have badly my boiling point! The water boils at 100 ℃! I can have syncope!" Mrs. Saucepan With-Water-in-a-Mountain-of-7,000-Metres-of-altitude was worried about the pressure. "Doctor, I come to take my blood pressure... My neighbour, who had low the boiling point had the other day a terrible sickness...". The doctor checked her pressure, and after that he said, "Okay, Mrs. Saucepan With-Water-in-a-Mountain-of-7,000-Metres-of-altitude, you have a surprising figure of 71 ℃".
"But Doctor, I have very badly my boiling point! The water boils at 100 ℃! I'm about to give me a dizzy!" Mrs. Pressure Cooker-With-Water was worried about her pressure. "Doctor, I come to take my blood pressure... My neighbour, who had high the boiling point, had the other day a thrombosis..." The doctor checked her blood pressure, and after that he said, "Okay, Mrs. Pressure Cooker-With-Water, you have a amazing pressure of 150 ℃".
"But Doctor, I have very badly my boiling point! The water boils at 100 ℃! I can have a thrombosis!" Mrs. Saucepan-With-Water-In-The-Dead-Sea was worried about her pressure. "Doctor, I come to take my blood pressure... My neighbour, who had a high boiling point, had the other day a stroke...".
The doctor checked her blood pressure, and after that he said, "Okay, Mrs. Saucepan-With-Water-In-The-Dead-Sea, you have a pressure something amazing of 107 ℃".
"But Doctor, I have something wrong with my boiling point! The water boils at 100 ℃! I'm at risk of having a heart attack!" The doctor explained: "What is the temperature of boiling water? The question is simple, and we all know the answer: water boils at 100 ℃. It is right? Well, this answer is incorrect, or more properly speaking, is incomplete. The correct answer would be that water when it is subjected to a pressure of one atmosphere boils at 100 ℃. And the 'most correct' answer is that any liquid boils at the temperature at which the saturated liquid vapour is to the same pressure as the environment in which the liquid is".
He continued: "At sea level, water boils at 100 ℃. The pressure at sea level is one atmosphere (760 mmHg), and with this pressure the water boils at that temperature. Water boils in Mexico City, which is at an average altitude of 2250 m (therefore less atmospheric pressure; about 584 mmHg) between 90-95 ℃. In a mountain of 7,000 m, water boils at an amazing temperature of 71 ℃. In a pressure cooker, being in a container at greater pressure than atmospheric pressure, the water does not reach the boiling point at 100 ℃, but at a higher temperature. Therefore we are cooking food in water at a temperature of 130, 140 or 150 ℃. And this temperature is what makes food is cooked before. In the Dead Sea, which is an salt lake located at 416.5 meters below sea level between Israel, Jordan and the Palestinian Territory (is in fact the lowest place on Earth) water boils at 107 ℃...".
The doctor reflected: "any knowledge requires contextualization. For this contextualization we must add dimensions that are not contained in scientific discourse: 1) Social or relational dimension (things happen in the field of interaction between people); and 2) The historical dimension (knowledge has to do with people who have their specific history and motivation, is the specific knowledge of a particular moment in the life of individuals or organizations). The disease is expressed or is experienced in situations of patient's daily life: work and family situations.... If symptoms cannot be contained within of the situation, using certain resources (changes of behaviour, postures, exercises, spaces...), the person has to leave the situation (to rest, toileting, taking pills...); at this time is when we can say that the disease is born".
Once upon a time... when, the Mr. Red Ball 11 of the American Billiard consulted the family doctor (Figure 4).
Mr. Red Ball 11 was a 58-year-old man with non-insulin dependent diabetes mellitus who has been well controlled with oral antidiabetic drugs and has never had high blood pressure and he is ex-smoker. Mr. Red Ball 11 work as bus driver; he emigrated from a poor area many years ago; he is married and father of three children, the oldest and the youngest are women aged 28 and 18 respectively - the Miss Yellow Ball 1 and the Miss White Ball - and the middle son is a 27-year-old male, named Young Blue Ball 2. All the children live in the house, as well as the paternal grandmother, the Mrs. Purple Ball 4, although she assists during the day to a social centre for old people. Among them, they are working, Mr. Red Ball 11, the mother (who name is Miss Orange Ball 5, and who suffers from dysthymia), the Young Blue Ball 2, and Miss Yellow Ball 1, reason why its economic situation is enough accommodated. Miss Orange Ball 5 works as a cook in a senior centre. The Young Blue Ball 2 is ceramist of profession. Miss Yellow Ball 1 is store clerk and seems satisfied with her job. The little Miss White Ball studies, but is in a situation of school failure.
Mr. Red Ball 11 came to the clinic for a routine check of his diabetes, which he kept very well regulated. But, this time the patient provided self-checks around 160 mg/dl of basal glycaemia. "Hmmm", said the doctor. "I'll also take your blood pressure".
Mr. Red Ball 11 had a striking blood pressure of 185/90 mmHg. "I will request a complete blood count, biochemical profile, systematic urine and proteinuria in urine for 24 hours, and I will see you again for the BP and collection of analytical results..." explained the doctor. At subsequent visits, the BP remained fairly elevated, and in the follow-up examinations the baseline glycaemia was of 313 mg/dl and Hb A1C of 10.7%. The rest of the explorations were within normalcy. "I have to increase the dose of the antidiabetic and I prescribe an ACEI, since I have just diagnosed to you of hypertension. I'll see you in two weeks for follow-up", the doctor told to the Mr. Red Ball.
After these two weeks Mr. Red Ball 11 said: "I have lost weight..., about 5 kg in the last month, and I feel dizzy, tired and my legs are swollen. I take my medication without mistakes and I do the diet well, but..." His capillary glycaemia was 268 mg/dl and BP was 180/90 mmHg. "I need sick leave", said Mr. Red Ball 11.
In the subsequent checks, in the face of the clearly unfavourable evolution of his glycaemia figures, the doctor warns Mr. Red Ball 11 of the possibility of insulin therapy, and when it is finally prescribed, the patient thinks it convenient to wait a little longer, stating that a family incident may have influenced the lack of control.
Three days before the final indication of insulin therapy, Mr. Red Ball 11 went to the office to request a sick leave for his wife, Mrs. Orange Ball 5. "But, Mr. Red Ball 11, I need to visit your lady before I give her sick leave", said the doctor.
A few days later, Mrs. Orange Ball 5 was at the consultation: I am mentally affected after the house escape of my youngest daughter, Miss White Ball, and we do not know where she is. I also have a series of family problems regarding Miss White Ball, which has a sentimental relationship with the young Blue Ball 16, which we do not accept in the family because we believe it has negative influences on her. During this same period of time, the Young Blue Ball 2 also consulted with the doctor: "I need the sick leave, doctor".
Young Blue Ball 2 had been attended several times in the hospital emergency service due to several anxiety crises.
After this, Miss Yellow Ball 1 also was to consultation: "My sister, Miss White Ball, gets along well with me... And her boyfriend, the Young Blue Ball 16, surely knows the place where she is. The day before the she run away from home, it was delivered to Miss Ball White the notes of the school, having suspended almost all the subjects. In addition, she gets along well with a cousin, Miss Green Ball 6, and with an aunt, Mrs. Green Ball 14..." explained Miss Yellow Ball 1.
The doctor contacted on several occasions with Miss Yellow Ball 1 to follow specifically the evolution of the familiar dynamics during this phase of the crisis. Miss White Ball ended up returning from her escape and accepted, at the request of Mrs. Orange Ball 5, a specialized interview with the primary care psychologist.
After a few weeks, Miss White Ball was accompanied by Mrs. Orange Ball 5 to the consultation, with headaches and insomnia. She also referred to their relational problems (including those that had coincided in time with the family crisis), thus starting with the family doctor a direct relationship.
Mr. Red Ball 11 normalized his blood pressure (continued on diet and with ACEI), his weight, and his glucose figures in about 30 days (without any significant change in medication at last). Mrs. Orange Ball 5 requested to doctor back to work, and the Young Blue Ball 2 (who was treated with antidepressants) returned also, in forty days, to working.
The family doctor thought, "Miss White Ball 'placed the rest of the balls in the triangle, and pulled out from the opposite side of the table': the health problem was Miss White Ball's run away from home, and so her blow against Mrs. Orange Ball 5, who hits Miss Yellow Ball 1, and the Young Blue Ball 2, the Young Blue Ball 16, and Miss Green Ball 6, and Mrs. Green Ball 14, and with Mrs. Purple Ball 4 , and finally against Mr. Red Ball 11...".
And he asks himself: "Is it a family in continuous dysfunction, or at that moment was a family that works acceptably but is going through a crisis situation, or was it a family in continuous dysfunction accentuated by a crisis? Is there a single reason or several reasons? Are the family's medical problems a temporary coincidence with the crisis that is happening?"
Discussion and Conclusion
In family medicine we need to know that "dividing an elephant in half does not produce two small elephants". As human systems are infinitely complex, we cannot understand everything (or dividing it into parts); we have cognitive limitations. The division of disciplines makes it impossible to take what is woven together. So, to maintain this systemic approach, is required, increasingly, a general practitioner. It has been shown that an increased use of specialists is not associated with better health and it increases costs. It is best to keep the patient in primary care whenever possible. Having a holistic or comprehensive view of the patient is to take into account the interrelationships of the various dimensions of a person and see the whole as greater than the sum of its parts, as well as the acceptance of integration, or seeing the whole as an single fact [2,5,12-15].
Continuity of care is a defining characteristic of family medicine. Continuity of care is difficult and requires a lot of resistance in extreme conditions of uncertainty and resists the many vicissitudes of interpersonal relationships long term. The family doctor is in the same medical office for a long time and developing relationships with patients and their contexts, and understanding their views and knowledge, so that he can better interpret the signs and symptoms of the disease of those people. The family doctor establishes long-term relationships with patients, their families and communities, and also acts as a witness to the patient experience. It is someone prepared to observe what happens over time. The continuity of relationships between family doctor and patient in their environment builds trust and creates an appropriate healing context. The family doctor, in his work, gets to know the long-term contextual factors, so he is the only professional who comes to know the true natural history of disease [16-22].
The disease is a relational concept. It relates to the contexts. The disease appears between the person and their relationships with the contexts; there are not isolated contexts. The disease depends on individual contexts and in turn produces consequences in contexts: social, cultural, economic, environmental and political in which it occurs. Perform a contextualized intervention it is to serve people, to know the patient, not only their medical history, but their preferences, beliefs, ideals, desires of information and participation, family, work, community, cultural context, and their relationships [23-25].
The family doctor not looking at the patient's family is not being aware of a basic law of Nature: the "billiard ball" effect or that the family affects the health of its members and is affected by them. The family physician should be alert to signs and indicators that shows the need to examine family factors more thoroughly, as well as being aware of the family life cycle (transitions and turning points), with their stages and their associate problems. What do we need to know about the family in terms of health? Well, it depends on the use that we think to make with that information. And how can we organize the almost limitless data that can be collected from families? We need to find "the system that defines the problem": the set of people affected by the problem, both in terms of maintenance as of treatment [2,26-31].
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Jose Luis Turabian, Department of Family and Community Medicine, Health Center Santa Maria de Benquerencia, Regional Health Service of Castilla la Mancha (SESCAM), Toledo, Spain.
© 2017 Turabian JL. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.