Holistic Diagnosis & Comprehensive Management
Content
Holistic Diagnosis and
Comprehensive Management
Dr. Oryzati Hilman Agrimon, MSc.CMFM, PhD (C)
● PhD Candidate in General Practice/ Family Medicine,
the University of Adelaide, Australia
● Lecturer
Department of Public Health and Family Medicine
Faculty of Medicine and Health Sciences
Universitas Muhammadiyah Yogyakarta
Discussion Topics
• The Role of Family Doctor
• Level of Physician Involvement in the Family
• The Application of Holistic Approach in the
Management of Patient
The Five-Star Doctor
• Peran “Five-star Doctor” (WHO, 2000) dalam
suatu sistem kesehatan yg merespon kebutuhan
masyarakat:
Health
care
provider
Decision
maker
Manager
FIVE-STAR
DOCTOR
Community
leader
Communicator
• Modifikasi “Five-star Doctor” menjadi
“Five-star Family Doctor” oleh Philippine
Academy of Family Physicians (PAFP, 2001)
Bio-medicalclinical science
Health
care
provider
Health
Organization & Administrator/
Management
Manager
CME & CPD, IT
EBM & Research
Life-long
learner/
researcher
FIVE-STAR
FAMILY
DOCTOR
Counselor/ Communication &
Advocate Counseling Skills
Health
educator
Health Promotion,
Disease Prevention &
Life-style modification
Levels of Physician Involvement in the Family
• Five Levels of Physician Involvement (LPI) in the
Family (Tingkat Keterlibatan Dokter dalam
Keluarga): (Doherty & Baird, 1986 in Goh et al
2004, McDaniel et al 2005, Sloan et al, 2002)
● Level 1: Minimal emphasis on the family
(Penekanan yang minimal pada keluarga)
● Level 2: Providing medical information & advice
(Memberikan informasi & nasihat medis)
● Level 3: Providing feelings and support
(Memberikan perhatian pd perasaan & dukungan)
● Level 4: Family assessment & counseling
(Penilaian keluarga & konseling)
● Level 5: Family Therapy
(Terapi keluarga)
Patient
Family
Physician
(Doherty & Baird, 1980)
• Notes:
● Family-centered FD thinks ‘family’ in every 10-15’
encounter with a patient
● Most non-family-oriented physicians operate at level 1
● Most FDs move between levels 2 and 4 at any given
time
● FDs who pay attention to the family save time, energy &
money & yield favorable results for the physician & the
patient
● To provide quality health care, family-oriented physicians
use the most basic resources available to them: the
patient & his/her family
→ the family is the natural partner in health care
● The therapeutic triangle in medicine: involves the
clinician, the patient & the family working together in a
medical-care partnership
• Level 1: Minimal emphasis on the family
● The interaction is limited to the patient only
● The doctor-centered encounter: one way communication
● The physician focuses on gathering biomedical & family
information needed to make the correct diagnosis & treatment
• Level 2: Providing medical information & advice
● The family is a partner in care
● Collaborative information exchange
● The physician communicates information clearly to patients &
families: teaching at least 1 family member about the
patient’s illness
● The physician solicits patient & family input into diagnostic &
treatment planning
• Level 3: Providing feelings & support
● FD goes beyond “the problem” to actively address emotional
issues of the individual patient & the family
● FD demonstrates emphatic listening and elicits expressions
of feelings & concerns related to the patient’s conditions & its
effect on the family
● FD normalizes feelings & emotional reactions to illness,
encouraging family members in their efforts to cope as a
family & identifying family dysfunction
• Level 4: Family assessment & counseling
● FD assesses the relationship between the illness problem
and the family dynamics
● FD seeks to work to catalyze change in psychosocial health
through encounters with the patient and/ or the family
● Brief counseling: may occur over 1 or several visits; common
in practice & can be extremely effective; involves identifying
problems & potential solutions;
● If the problem is not complex & long-standing, work with
family to achieve change
● If the problem is entrenched or family counseling is not
effective, make a referral to family therapist
• Level 5: Family therapy
● FD meets with the patient & the family regularly for multiple
sessions to change unhealthy patterns within the family
system
● Medical family therapy is intensive specialty care delivered by
professionals with advanced psychotherapy training
Application of Holistic Approach
in the Management of Patient
• Perumusan masalah dan penyelesaian masalah
kesehatan tidak didekati dari satu aspek saja
Holistic
History
Taking
Bio-psycho-social
model
Holistic
Diagnosis
Holistic
Management
A Case with 2 Scenarios…
• A 45-year-old insurance broker who is under
a lot of work stress recently because his
company management has set some new
business targets that he has difficulty in
meeting. He is not sleeping well at night an
feels rather tired in the day. He starts to
think that he cannot cope with his work
because his health is ailing. He looks for
signals of illnesses from his body and he
noticed that he has some belching. So he
goes to see a doctor……..
A: What happens… if……???
• If he consults a gastroenterologist first, he
will most likely be subject to an upper GI
endoscopy and H-pylory testing, which most
likely to be negative. The gastroenterologist
will reassure him that there is nothing wrong
with him and prescribe some empirical
symptomatic treatment. He still feels tired
and starts to look for other symptoms, shop
for doctors and undergo further
investigations to find out what is wrong with
him…….
B: What happens… if……???
• If he consults a family doctor first, he will
be evaluated on not only his belching but also
his underlying concerns, psychological state
and social situation. The family doctor will be
able to detect his work stress in addition to
his presenting symptom. Apart from deciding
on whether further investigation and drug
treatments for the belching are needed, the
family doctor will also look for any
psychological disease and offer counseling to
his stress. After seeing the family doctor,
he will try to solve his problem by stress
management instead of using the health
service.
Exploring both the
Disease & illness
experience
Understanding
the whole
person
Finding
Common
ground
Physical, history, lab
Disease
Patient
Presents
cues
CONTEXT
PROBLEMS
PERSON
Illness
Illness
Mutual
Decision
Disease
Ideas, expectations
Feelings, effect on
functions
Enhancing
Patient-doctor
relationship
GOALS
ROLES
Incorporating
Prevention and
Health promotion
Being realistic
The Patient Centered Clinical Method
Culture
Community
The Mandala of Health:
A model of human
ecosystem
lifestyle
Personal
behavior
Sick
care
system
spirit
body
Human
biology
Psycho-socioEconomic
Environment
work
mind
Physical
environment
Human-Made Environment
Biosphere
• Holistic History Taking:
- History of patient, including “Personal Social History”:
education, work, family, marriage, lifestyle
- Exploring both disease & illness
- Identification of risk factors
- Psycho-social analysis of family dynamics:
using family assessment tools
• Holistic diagnosis (bio-psycho-social analysis)
- Medical diagnosis
- Psycho-social diagnosis: result of psycho-social
analysis of family dynamics
• Holistic intervention:
- Level of physician involvement in the family (LPI):level 2-4
- Medical intervention based on EBM
- Psycho-social intervention: individual & family
counseling (not only giving advice)
- Preventive measures
Algoritme Manajemen Pasien dengan
Pendekatan Holistik
•
History of
Patient:
Personal
social
history
Disease &
illness
Risk
factors
Impact
of
Illness
Genogram
Patient
Family Map
Holistic
History
Taking
Family
assessment
tools
Physical
Exam
Investigations
Medical
Diagnosis
Medical
Intervention
Based on EBM
Preventive Measures
Holistic
Diagnosis
Comprehensive
Management
Psychosocial
Diagnosis
LPI: level 2-4
Psychosocial
Intervention
Family
Life Cycle
Family
Life Line
Family
APGAR
Family
SCREEM
• Contoh diagnosis yg holistik:
● OMSK berisiko lanjut pada balita dengan
kurangnya kepedulian keluarga
● Dampak bio-psiko-sosial HIV/AIDS pada pasien &
keluarganya
● Pengaruh faktor genetik, sikap & perilaku serta
dukungan pasangan thd keberhasilan pengobatan
TBC & DM pada kepala keluarga
● Asma bronchiale tidak dalam serangan &
hipertensi terkontrol pada kepala keluarga dg
faktor risiko tempat tinggal & masalah psikososial
● PPOK pada kepala keluarga yang tidak bekerja
dengan perilaku merokok yang kontinyu
● Hipertensi pada istri sebagai pencari nafkah
utama keluarga terkait dengan stressor psikis
● Diagnosis Holistik
PPOK Derajat Ringan Eksaserbasi Akut pada LakiLaki Paruh Baya Tidak Menikah, Mantan Perokok
Sedang dengan Status Ekonomi Rendah dengan
Ketidaktahuan dan Kekhawatiran terhadap
Penyakitnya dengan Fungsi Keluarga yang Kurang
Sehat pada Rumah Tangga yang Tidak berperilaku
Hidup Sehat
● Manajemen Komprehensif:
* Promotif =
* Preventif =
* Kuratif =
* Rehabilitatif =
Learning Points...???
• Thank you for your attention…!
• Questions are most welcome…!
Wassalamu’ alaikum Wr.Wb
Comprehensive Management
Dr. Oryzati Hilman Agrimon, MSc.CMFM, PhD (C)
● PhD Candidate in General Practice/ Family Medicine,
the University of Adelaide, Australia
● Lecturer
Department of Public Health and Family Medicine
Faculty of Medicine and Health Sciences
Universitas Muhammadiyah Yogyakarta
Discussion Topics
• The Role of Family Doctor
• Level of Physician Involvement in the Family
• The Application of Holistic Approach in the
Management of Patient
The Five-Star Doctor
• Peran “Five-star Doctor” (WHO, 2000) dalam
suatu sistem kesehatan yg merespon kebutuhan
masyarakat:
Health
care
provider
Decision
maker
Manager
FIVE-STAR
DOCTOR
Community
leader
Communicator
• Modifikasi “Five-star Doctor” menjadi
“Five-star Family Doctor” oleh Philippine
Academy of Family Physicians (PAFP, 2001)
Bio-medicalclinical science
Health
care
provider
Health
Organization & Administrator/
Management
Manager
CME & CPD, IT
EBM & Research
Life-long
learner/
researcher
FIVE-STAR
FAMILY
DOCTOR
Counselor/ Communication &
Advocate Counseling Skills
Health
educator
Health Promotion,
Disease Prevention &
Life-style modification
Levels of Physician Involvement in the Family
• Five Levels of Physician Involvement (LPI) in the
Family (Tingkat Keterlibatan Dokter dalam
Keluarga): (Doherty & Baird, 1986 in Goh et al
2004, McDaniel et al 2005, Sloan et al, 2002)
● Level 1: Minimal emphasis on the family
(Penekanan yang minimal pada keluarga)
● Level 2: Providing medical information & advice
(Memberikan informasi & nasihat medis)
● Level 3: Providing feelings and support
(Memberikan perhatian pd perasaan & dukungan)
● Level 4: Family assessment & counseling
(Penilaian keluarga & konseling)
● Level 5: Family Therapy
(Terapi keluarga)
Patient
Family
Physician
(Doherty & Baird, 1980)
• Notes:
● Family-centered FD thinks ‘family’ in every 10-15’
encounter with a patient
● Most non-family-oriented physicians operate at level 1
● Most FDs move between levels 2 and 4 at any given
time
● FDs who pay attention to the family save time, energy &
money & yield favorable results for the physician & the
patient
● To provide quality health care, family-oriented physicians
use the most basic resources available to them: the
patient & his/her family
→ the family is the natural partner in health care
● The therapeutic triangle in medicine: involves the
clinician, the patient & the family working together in a
medical-care partnership
• Level 1: Minimal emphasis on the family
● The interaction is limited to the patient only
● The doctor-centered encounter: one way communication
● The physician focuses on gathering biomedical & family
information needed to make the correct diagnosis & treatment
• Level 2: Providing medical information & advice
● The family is a partner in care
● Collaborative information exchange
● The physician communicates information clearly to patients &
families: teaching at least 1 family member about the
patient’s illness
● The physician solicits patient & family input into diagnostic &
treatment planning
• Level 3: Providing feelings & support
● FD goes beyond “the problem” to actively address emotional
issues of the individual patient & the family
● FD demonstrates emphatic listening and elicits expressions
of feelings & concerns related to the patient’s conditions & its
effect on the family
● FD normalizes feelings & emotional reactions to illness,
encouraging family members in their efforts to cope as a
family & identifying family dysfunction
• Level 4: Family assessment & counseling
● FD assesses the relationship between the illness problem
and the family dynamics
● FD seeks to work to catalyze change in psychosocial health
through encounters with the patient and/ or the family
● Brief counseling: may occur over 1 or several visits; common
in practice & can be extremely effective; involves identifying
problems & potential solutions;
● If the problem is not complex & long-standing, work with
family to achieve change
● If the problem is entrenched or family counseling is not
effective, make a referral to family therapist
• Level 5: Family therapy
● FD meets with the patient & the family regularly for multiple
sessions to change unhealthy patterns within the family
system
● Medical family therapy is intensive specialty care delivered by
professionals with advanced psychotherapy training
Application of Holistic Approach
in the Management of Patient
• Perumusan masalah dan penyelesaian masalah
kesehatan tidak didekati dari satu aspek saja
Holistic
History
Taking
Bio-psycho-social
model
Holistic
Diagnosis
Holistic
Management
A Case with 2 Scenarios…
• A 45-year-old insurance broker who is under
a lot of work stress recently because his
company management has set some new
business targets that he has difficulty in
meeting. He is not sleeping well at night an
feels rather tired in the day. He starts to
think that he cannot cope with his work
because his health is ailing. He looks for
signals of illnesses from his body and he
noticed that he has some belching. So he
goes to see a doctor……..
A: What happens… if……???
• If he consults a gastroenterologist first, he
will most likely be subject to an upper GI
endoscopy and H-pylory testing, which most
likely to be negative. The gastroenterologist
will reassure him that there is nothing wrong
with him and prescribe some empirical
symptomatic treatment. He still feels tired
and starts to look for other symptoms, shop
for doctors and undergo further
investigations to find out what is wrong with
him…….
B: What happens… if……???
• If he consults a family doctor first, he will
be evaluated on not only his belching but also
his underlying concerns, psychological state
and social situation. The family doctor will be
able to detect his work stress in addition to
his presenting symptom. Apart from deciding
on whether further investigation and drug
treatments for the belching are needed, the
family doctor will also look for any
psychological disease and offer counseling to
his stress. After seeing the family doctor,
he will try to solve his problem by stress
management instead of using the health
service.
Exploring both the
Disease & illness
experience
Understanding
the whole
person
Finding
Common
ground
Physical, history, lab
Disease
Patient
Presents
cues
CONTEXT
PROBLEMS
PERSON
Illness
Illness
Mutual
Decision
Disease
Ideas, expectations
Feelings, effect on
functions
Enhancing
Patient-doctor
relationship
GOALS
ROLES
Incorporating
Prevention and
Health promotion
Being realistic
The Patient Centered Clinical Method
Culture
Community
The Mandala of Health:
A model of human
ecosystem
lifestyle
Personal
behavior
Sick
care
system
spirit
body
Human
biology
Psycho-socioEconomic
Environment
work
mind
Physical
environment
Human-Made Environment
Biosphere
• Holistic History Taking:
- History of patient, including “Personal Social History”:
education, work, family, marriage, lifestyle
- Exploring both disease & illness
- Identification of risk factors
- Psycho-social analysis of family dynamics:
using family assessment tools
• Holistic diagnosis (bio-psycho-social analysis)
- Medical diagnosis
- Psycho-social diagnosis: result of psycho-social
analysis of family dynamics
• Holistic intervention:
- Level of physician involvement in the family (LPI):level 2-4
- Medical intervention based on EBM
- Psycho-social intervention: individual & family
counseling (not only giving advice)
- Preventive measures
Algoritme Manajemen Pasien dengan
Pendekatan Holistik
•
History of
Patient:
Personal
social
history
Disease &
illness
Risk
factors
Impact
of
Illness
Genogram
Patient
Family Map
Holistic
History
Taking
Family
assessment
tools
Physical
Exam
Investigations
Medical
Diagnosis
Medical
Intervention
Based on EBM
Preventive Measures
Holistic
Diagnosis
Comprehensive
Management
Psychosocial
Diagnosis
LPI: level 2-4
Psychosocial
Intervention
Family
Life Cycle
Family
Life Line
Family
APGAR
Family
SCREEM
• Contoh diagnosis yg holistik:
● OMSK berisiko lanjut pada balita dengan
kurangnya kepedulian keluarga
● Dampak bio-psiko-sosial HIV/AIDS pada pasien &
keluarganya
● Pengaruh faktor genetik, sikap & perilaku serta
dukungan pasangan thd keberhasilan pengobatan
TBC & DM pada kepala keluarga
● Asma bronchiale tidak dalam serangan &
hipertensi terkontrol pada kepala keluarga dg
faktor risiko tempat tinggal & masalah psikososial
● PPOK pada kepala keluarga yang tidak bekerja
dengan perilaku merokok yang kontinyu
● Hipertensi pada istri sebagai pencari nafkah
utama keluarga terkait dengan stressor psikis
● Diagnosis Holistik
PPOK Derajat Ringan Eksaserbasi Akut pada LakiLaki Paruh Baya Tidak Menikah, Mantan Perokok
Sedang dengan Status Ekonomi Rendah dengan
Ketidaktahuan dan Kekhawatiran terhadap
Penyakitnya dengan Fungsi Keluarga yang Kurang
Sehat pada Rumah Tangga yang Tidak berperilaku
Hidup Sehat
● Manajemen Komprehensif:
* Promotif =
* Preventif =
* Kuratif =
* Rehabilitatif =
Learning Points...???
• Thank you for your attention…!
• Questions are most welcome…!
Wassalamu’ alaikum Wr.Wb
