Educating Physicians for Brazilian Health Clinics
University of Sao Paulo
March 24, 2006
Supplemental material
What do People Want and Expect from their Physician
1. An expert clinician.
People want a physician who is well informed and whose clinical skills are up to date.
They want a physician who can access and assess information about their condition,
whether it is common or rare, who can recommend and provide treatment for most
conditions most of the time but who knows when to recommend further care by
others, taking into account each individual patient’s family, community, and cultural
context. Physicians should also be able to respond to special needs of minority
groups, the disabled and disadvantaged. Patients expect their personal physicians to
be well-educated, to remain up to date concerning medical matters, and to sustain
clinical competence over a lifetime.
2. A skilled scholar, scientist, and appraiser of new medical knowledge.
Patients expect their personal physician to be able to recognize knowledge gaps and
to have skill in self directed learning, asking clear questions and finding trustworthy
answers efficiently. Physicians must understand the scientific method and be able to
apply knowledge from multiple sources to clinical problems besetting individual
patients as well as health issues in the community. Such a physician is an
“information master”, able to identify the strengths and weaknesses of published
research - both qualitative and quantitative - and to apply research results to practice.
This expectation includes being up to date with current knowledge and being able to
facilitate the understanding of each patient as to the meaning of information relevant
to them. Physicians should be able to discuss the potential benefits, costs and risks of
investigations and treatments in a way that empowers the patients and their families
to make choices that balance individual, community, and societal interests.
3. A skilled interviewer.
Patients want physicians to “enter the patient’s world”(ref) and understand problems
from their point of view, taking into account the patient’s cultural background and
sometimes working with an interpreter. Physicians need to respond appropriately to
their patients’ feelings with empathy, respect and sincerity. Physicians need to
educate patients about their problems in language they can understand and empower
them to prevent as well as cope with illness and to cease unhealthy behaviors.
Furthermore physicians must effectively communicate with family members,
individually or as a group, with an awareness of appropriate confidentiality.
4. A health advocate.
Physicians must therefore have an awareness of the multiple determinants of health
and be pro-active in forming healthy public policy. Patients want community-based
physicians to treat them individually and also intervene at a population level to
improve the health of the community.
5. Adaptable
Patients want their physician to be able to adapt to change. They must be willing to
reconsider previous convictions and able to learn from others - including patients,
colleagues and other professionals. Patients’ personal physicians need a vibrant
curiosity, a passionate commitment to seek the truth, and the honesty and integrity to
use knowledge for the maximum benefit of patients
6. Collaborative.
Personal physicians must work effectively as a member of a team including other
health care workers – not necessarily as the team leader. The team may be small or
large, administratively defined or virtual, and is likely to change over time for any
given individual. Collaboration implies use of community and other health care
resources appropriately. It includes working effectively with patients and their
families without having to be in charge and being able to find common ground when
there are differences of opinion.
7. A steward of precious resources.
Personal physicians need to make appropriate referrals to community resources and
other professionals to optimize their patients’ health. Physicians need to assist
patients and their families to understand when any use of resources (especially those
that are costly or rare) is not appropriate. Physicians require skills in using and
explaining the concepts of sensitivity, specificity and predictive value to avoid
unnecessary tests. When a conflict arises between the interest of patients and the
interest of patients’ communities, physicians must be able to discuss related issues
with those affected and seek appropriate advice.
8. A healer.
Physicians must be able to use their personal strengths and attributes to encourage
healing and provide moral support for patients. This requires a non-judgmental
approach to people and an awareness of one’s own personal assets and limitations.
Physicians must recognize when they themselves need help and health care. They
must also understand their own personal biases so that they can limit their
interference with patients’ care decisions. Physicians need to recognize the
psychological effects on themselves and their patients of the power imbalances
associated with relationships where patients trust their most intimate and vulnerable
selves with another person who is not expected to do likewise. The physician as a
person must accept that they cannot be all things to all people and be able to say “no”
appropriately and without guilt. To remain effective, physicians must meet their own
personal and family needs and have effective support systems.
Educating Physicians for Brazilian Health Clinics
Most common problems in the
OFFICES OF U.S. PRIMARY CARE physicians
PHYSICIANS (1995-1999)(Workload in the Office)
Reason for visit
---------------general medical examination
cough
sore throat
well baby examination
follow-up visit
fever
earache
hypertension
head cold, upper respiratory infection
skin rash
nasal congestion
back pain, ache, discomfort
blood pressure check
headache
new/renewed medication
diabetes mellitus
chest pain
abdominal pain
vaccinations/immunizations
vertigo-dizziness
knee pain, ache, discomfort
low back pain, ache, discomfort
tiredness, exhaustion
test results
shoulder pain, ache, discomfort
diarrhea
shortness of breath
depression
neck pain, ache, discomfort
ear symptoms
Per 1000
Visits
-------83.84
56.16
34.80
34.56
29.69
28.40
21.80
21.20
19.20
18.66
17.78
17.63
16.63
16.10
13.75
13.04
12.11
10.44
9.56
9.40
8.51
8.42
8.27
7.55
6.97
6.79
6.61
6.58
6.50
Table 2 Important problems where immediate or
urgent intervention is required to prevent death
or serious injury:
Meningitis
Acute spinal chord compression
Cardiac arrest or ventricular fibrilation
Acute myocardial infarction
Acute cerbro vascular accident.
Acute laryngo tracheitis
Pneumothorax
Ectopic pregnancy
Anaphylaxis
Cyanosis
Shock
Unconsciousness
Adverse effects of extreme heat , cold or pressure.
Neonatal distress syndrome
Addisonian crisis
Acute bowel obstruction
Acute Broncheolitis
Dehydration
Situations requiring early detection of the problem
and intervention to prevent long term serious,
disabelling, or lethal outcomes.
Undescended testicle
Congenital heart disease
Congenital hip dislocation
Strabismus
Congenital deafness
Abnormal head growth
Psychomotor developmemntal delay
Speech delay
Wilsons disease
Phenylketonuria
Congenital hypothyroidism.
Screening for colon cancer
Screening for breast cancer
Screening for cervical cancer
Screening for hypertension
Table 3
Basket of Services Provided by the Canadian Family Physician Groups
(Ontario Family Health Teams)
Health assessment: This is considered a key strategy in the formalizing the physician
patient relationship. The health assessment includes a history, physical examination, and
appropriate diagnostic and screening tests..
Illness Prevention: Using evidence based practice guidelines appropriate screening and
provide reminder systems have been proven to increase the rate of preventive screening
procedures
Health Promotion: The assembly of a practice profile will assist in assessing the practice
priorities for improving life style and reducing the risk of illness.
Education and support for self-care: This strategy is to increase the component of the
ecology diagram in the self-care category and reduce people’s dependence on medical
care.
Diagnosis and treatment of episodic illness and injury: The family physician will be
skilled at diagnosing and treating acute illnesses on the basis of the common and
important problems.
Diagnosis and management of major illness and injuries: This care will be provided
initially by the family physician and then in appropriate collaboration with appropriate
specialists
Diagnosis and treatment of chronic illnesses: This is an area where the interdisciplinary
team can play a major role in appropriate collaboration with specialists to improve
quality of life and longevity of many individuals with chronic illness.
Co ordination and provision of rehabilitative services: Each network will need to
establish relationships with specialists, hospitals and community health care providers to
facilitate appropriate rehabilitation programs for recovering patients..
Supportive care: Supportive care for the frail elderly or the disabled should have the goal
of maintaining these individuals in the community as long as possible.
A 24\7 response for urgent problems. As already outlined patients will have access to a
telephone triage system.
Primary Reproductive care: This includes birth control counseling and provision of
appropriate methods, STD screening and treatment, pre conception counseling, diagnosis
of pregnancy and options counseling, ante natal care, labor and delivery care, immediate
maternal and newborn care.
Support for the terminally ill: Continuity of care is a very important part of terminal care
Primary Mental health care including psychological counseling: The physician should be
continuously identifying patients at risk for developing emotional or mental disorders.
Co ordination of referral to other health services. The network needs to establish formal
links with specialists and hospitals and community health services to be able to meet the
needs of their patient population..
Advocacy for the patient in the System. Lack of appropriate communication and co
ordination in highly specialized hospital systems often finds patients needs not being
appropriately met.