全科医学 第2讲 The Enhancement of Health and the Prevention of Disease学习课件

2014年3月3日ExampleforFamilyMedicinePaperTest

(Nov.6)一.BestChoice（Score1foreach）（）1.Whoareinanbestpositionforhelpingpatientstoimprovetheirhealth?A．Physicians B．GynecologistsC．Paediatricians D．GPs二.MultipleChoices（Score2foreach（）1.Whichcanbelistedastheminorproblems?A．CoughfortwodaysB．BackpainfortwodaysC．HighfeverfortwodaysD．TiredfeelingfortwodaysE．Redurinefortwodays三.NameExplanation（Score3foreach）1.WONCA2.Primaryprevention四.Question（Score10-15foreach1.Howmanydimensionsarethereinthecontinuityofcare?GPsareinanunrivaledpositionforimprovehealthPGsseeeachoftheirpatients,ontheaverage,threeorfourtimesayear.Manyofthesevisitsareforselflimitingproblemsinhealthypeople.Theyprovideanexcellentopportunityforhealthcounselingandtheearlydetectionofdisease.Becauseoftheirpersonalknowledgeofpatientsandtheirfamilies,GPsmaybeawareofresources,bothinnerandouter,thatareimportantforthemaintenanceorrecoveryofhealth.Insecondaryprevention,theycantakeresponsibilityforthewholeprocess,fromcasefindingthroughinvestigationtomanagementoftheproblem.GeneralPrinciplesSomepreventiveservicesforindividuals.Othersforcommunitiesandpopulations.ForGPsinmanycommunities,theepidemicofdiabetescallsforworkatthecommunitylevelaswellasthecareofindividualpatients.Preventiveservicesforindividuals

Primarypreventionincreasesaperson’sabilitytoremainfreeofdiseaseSecondarypreventionBetheearlydetectionofdiseaseorprecursorsofdisease-sothattreatmentcanbestartedbeforeirreversibledamagehasoccurredTertiarypreventionBethemanagementofestablisheddiseasesoastominimizedisability.Measurestomaintaincommunitiesandpopulations’healthinclude:CleanwaterFoodinspectionSanitationWastedisposalPollutioncontrolAccidentpreventionSocialservicesEarlydetectionofdiseasePromotionofHealthversusPreventionofDisease

Thecategorizationofpreventiveactivitiesintoprimary,secondary,andtertiarywasintendedtoapplytospecificdiseases.Healthpromotionisthedevelopmentofaperson’sgeneralresistanceresources(GRR).Healthisattainedthrough:ahealthyenvironmentbalanceddietphysicalfitnessthefosteringofcopingskills,self-confidence,andself-controlAntonovskyhasdescribedthisapproachassalutogenesis.PreventiveservicesHealthenhancement:counselingandinformation.Riskavoidance:ensuringthatpeopleatlowriskremainatlowrisk-forexample,immunization,accidentprevention.Riskreduction:identificationofindividualsathighriskfordiseaseinordertohelpthemreducetherisk.Earlyidentificationofdiseaseatthepresymptomaticstage(equivalenttosecondaryprevention).Complicationreductioninpatientswithestablisheddisease(equivalenttotertiaryprevention).Whatishealth?_BeelusiveThemeaningofhealthhasalwaysprovedtobeelusiveAccordingtotheConstitutionofWHO,healthis“astateofcompletephysical,mentalandsocialwell-beingandisnotmerelytheabsenceofdiseaseorinfirmity.”ForthegreatmajorityofpeoplethisrepresentsanimpossibleidealWhatishealth?–Bemeaningfulonlywhendefinedintermsofagivenperson

InthewordsofReneDubos(1965)“positivehealthisnotevenaconceptoftheidealtobestrivenforhopefully.Ratheritisonlyamirage,becausemanintherealworldmustfacethephysical,biologicalandsocialforcesofhisenvironment,whichareforeverchanging,usuallyinanunpredictablemannerandfrequentlywithdangerousconsequences.”Thewordshealthanddiseasearemeaningfulonlywhendefinedintermsofagivenpersonfunctioninginagivenphysicalandsocialenvironment.Whatishealth?-BeavalueHealthand“normality”alwayshavetobedefinedintermsofaparticularpersonorgroupinaparticularenvironment.Theperson’svaluesmustalsobetakenintoaccount.Healthisavalue,andtosomeitmaynotbethehighestvalue.Itissometimessacrificedintheserviceofothers.Itissometimessquanderedinthepursuitofpleasure,fame,orfortune.Whatishealth?-normsofclassandcultureValuejudgmentsalsoenterintophysicians’conceptsofhealth,especiallywhentheyconcernhumanbehavior.Inacceptingunthinkinglythenormsofhisorherownclassandculture,thephysicianmaynotevenrealizethatavaluejudgementisbeingmade.Itisimportant,therefore,tobeclearaboutwhatnormalmeans.TheMeaningofNormal_needtobeunderstoodToidentifyindividualsathighriskrequiresanunderstandingofthemeaningofnormal.Inthehistoryofmedicine,fewerrorshaveledtosomuchharmasthefailuretobepreciseaboutthemeaningoftheterm.TheMeaningofNormal-theriskofharmisespeciallygreatAlthoughpresentwhenthephysicianisassessingandtreatingillness,theriskofharmisespeciallygreatinpreventivemedicineforherethephysicianisidentifyingabnormalitiesinpatientswhohavenotcomefortreatmentofsymptomsorwhohavecomewithsymptomsthatbearnorelationtotheidentifiedabnormality.Identificationoftheabnormalitymaythenleadtotreatmentthathasrisksandcosts.Attheveryleastthepatientwillhaveananxietyheorshedidnothavebefore.ProbabilityofobtaininganabnormalresultwhenmultipletestsaredoneNumberofIndependentTestsPercentageofTimesanAbnormalResultisFound152104196261040206450929099FromGalenandGambino,1975.WhataretheimplicationsoftheseobservationsforGP?(1)1. Injudgingthesignificanceofafinding,itisimportanttoascertainthattheresultisnotoneextremeofanindividualvariation.Agoodexampleofthisisthetendencyofbloodpressuretobehigheratthefirstthanatsubsequentreadings.Hencetheneedtoestablishthepatient’snormalrangeofvariationbeforeembarkingontreatmentforhypertension.2. Inusingpercentilechartsasthecriterionfornormality,thephysicianshouldbearinmindthemeaningof“normal”and“abnormal”results. WhataretheimplicationsoftheseobservationsforGP?(2)Injudgingtheabnormalityofaresult,ratherthanusingthestatisticalaverageornormalrangeasastandard,thephysicianshould,whereitisavailable,usethereferencevalue.4. Becauseofthelong-termrelationshipwithpatients,thefamilyphysicianisinagoodpositionforobtainingbaselinevaluesfrompatients.Thisenablesthephysiciantocomparesubsequentreadingsonthesamepatientwiththisbase­linevalue—apotentiallymuchmoreusefulcomparisonthanthatwitha“normalrange.”

WhataretheimplicationsoftheseobservationsforGP?(3)5. Becausetheycareformoreorlessunselectedpopulations,familyphysiciansareinanexcellentpositiontodeterminetherangeofnormalityformanykindsofvariables.Thisisoneofthemostusefulkindsofresearchafamilyphysiciancanundertake.6. Familyphysiciansshouldbeconstantlyaware,whendealingwithfamilyandpersonalproblems,thatitisveryeasytoconveyvaluejudgmentswithoutknowingthattheyaredoingso.TheEvaluationofScreeningandCaseFinding(P189)Tojustifytheapplicationofascreeningorcase-findingprocedure,thefollowingconditionsshouldbefulfilled:

1. Thediseaseinquestionshouldbeaserioushealthproblem.2. Thereshouldbeapresymptomaticphaseduringwhichtreatmentcanchangethecourseofthediseasemoresuccessfullythaninthesymptomaticphase.3. Thescreeningprocedureandtheensuingtreatmentshouldbeacceptabletothepublic.4. Thescreeningprocedureshouldhaveacceptablesensitivityandspecificity.Thescreeningprocedureandensuingtreatmentshouldbecost-effective.SalutogenesisSwitcheourperspectivefromthecausesofdiseasetothemaintenanceandimprovementofhealth.Itrecognizesthatstressorsareuniversalandomnipresent,butnotnecessarilypathological.Theirpathogenicitydependsonthecharacterofthestressorandtheresourcesavailabletotheindividual.Antonovsky(1987)attributessuccessfulresistancetoasenseofcoherence(SOC)thathasthreecorecomponents:ThreecorecomponentsofSOCComprehensibilityStressors,eitherinternalorexternal,shouldmakecognitivesensetotheperson.ManageabilityTocopewiththestressors,resourcesshouldbeavailableeithertothepersonorhisorhersupporters.MeaningfulnessThepersonshouldfeelthattheexperienceiscongruentwithhisorherbeliefsandvalues.SOCAnexpressionofthefitbetweenanindividualandhisorhersocialenvironment.Thepersonmustfeelthatheorsheisvaluedandrewardedathome,atwork,andinothersocialcontexts.Theaffectivere­sponsetostressfulexperienceoftenbypassesoroverridesthecognitive.Thedevastatingeffectofunemployment,forexample,canloweraperson’sfeelingofself-worth,reducethesenseofbelonging,andcuthimorherofffromamajorsourceofsocialapproval.Unemploymentisassociatedwithhighratesofillnessandincreaseddeathrates.Self-AssessedHealthandMortality

RespondentswithpoorersubjectivehealthstatusexperiencedgreatermortalityRespon­dentsmayhavebeenintuitivelyawareoftheirbodilystateinawaythatwasnotreflectedintheobjectiveevidenceofhealthstatus.Alternatively,theirassess­mentmayhavereflectedasenseofcoherence,orlackofit,whichexertedanindependenteffectontheirsubsequenthealth.Self-assessmentofhealthcovarieswitheducation,maritalstatus,andincome.Foranygivenlevelofobjectivehealthstatus,thosewhohavelesseducation,lowerincome,andwhoareunmar­riedhavepoorerself-assessmentsofhealth.whatpeoplesayabouttheirhealthshouldbetakenseriouslyevenifitcontradictsotherevidence..

PrinciplesofPHE(P196)-1Testsandproceduresarerepeatedatintervalsdeterminedbyepidemiologicalevidence,notbyarbitrarychoice.Wherefeasible,thesearegroupedinto“packages,”sothatthenumberofvisitsthepatienthastomakeisreduced.PrinciplesofPHE(P196)-2Maximumuseismadeoftheopportunityforcase-findingprovidedbyvisitsforallpurposes.Inoneyear,70percentofthepracticepopulationisseenatleastonce.Theaveragenumberofvisitsforeachpatientisaboutfourperyear.Inthecourseoffiveyears,virtuallythewholepopulationofthepracticewillpassthroughthephysician’soffice.Arelativelystraightforwardprocedurelikedetectionofhypertensioncanbeperformedalmostentirelyasacase-findingmaneuver.Screeningtestsandproceduresarenotincludedunlessthereisgoodevidencefortheireffectiveness.Forexample,thereisnojustificationforincludingachestx-ray.GradingtheeffectivenessofaninterventionI.Evidenceobtainedfromatleastoneproperlyrandomizedcontrolledtrial.Ⅱ-1.Evidenceobtainedfromwell-designedcohortorcase-controlanalyticstudies,preferablyfrommorethanonecenterorresearchgroup.Ⅱ-2.Evidenceobtainedfromcomparisonsbetweentimesorplaceswithorwith­outtheintervention.Dramaticresultsinuncontrolledexperiments(suchastheresultsoftheintroductionofpenicillininthe1940s)couldalsoberegardedasthistypeofevidence.III. Opinionsofrespectedauthorities,basedonclinicalexperience,descriptivestudiesorreportsofexpertcommittees.A. Thereisgoodevidencetosupporttherecommendationthattheconditionbespecificallyconsideredinaperiodichealthexamination.B. Thereisfairevidencetosupporttherecommendationthattheconditionbespecificallyconsideredinaperiodichealthexamination.C. Thereispoorevidenceregardingtheinclusionorexclusionoftheconditioninaperiodichealthexamination,andrecommendationsmaybemadeonothergrounds.D. Thereisfairevidencetosupporttherecommendationthattheconditionbeexcludedfromconsiderationinaperiodichealthexamination.E. Thereisgoodevidencetosupporttherecommendationthattheconditionbeexcludedfromconsiderationinaperiodichealthexamination.Table9.4P221ConditionMeasuresRecommendationLowbirthweightSmokingcessationcounselingAGastrointestinalandrespiratoryinfectioninnewbornCounselingonbreast-feedingAIrondeficiencyanemiaininfantsCounselingonbreast-feedingBTable9.8P225ConditionMeasuresRecommendationFalls/injuryMultidisciplinarypost-fallassessmentAProgressiveincapacitywithagingHomevisit-inquiryintophysical,psychological,andsocialcompetenceB*HypertensionBloodpressurereadingBHearingimpairmentInquiry,whisperedvoiceoraudioscopeBDiminishedvisualacuitySnellensightcardBClinicalGuidelinesThesheervolumeofevidencenowavailablemakesitimpossibleforanyonephysiciantobasehisorherpracticeonhisorherowncriticalreviewoftheliterature.Tomeetthisneed,institutions,academicbodies,professionalgroupsandothershavestartedtodeveloprecommendationsorguidelinesonmatterssuchasdiagnostictests,managementofdiseaseandpreventiveprocedures.Theprocessvariesfromonegrouptoanother.Sometimestheguidelinesaredevelopedbyagroupofexpertsonthesubjectinquestion.Theproblemwiththisisthatexpertsdevelopenthusiasmsfortheirsubjectsandmaybeinclinedtobrushasidecriticalevidence.Evenwhendissentingvoicesareraised,theymayfinditdifficulttogainahearing.Theprocessis“topdown.”Recommendationsarehandeddowntopractitionerswithouttheopportunityoffeedbackwhiletheguidelinesarebeingdeveloped.Thismaysetthestagefordisputesbetweenpractitionersandexperts,asoccurredinthecaseofcholesterolscreeninginOntario.TheprocessdesignedbytheDutchCollegeofGeneralPractitioners(NHG)isanexampleoftheopposite“bottomup”approach,inwhichpractitionersinitiateandparticipateinthewholeprocess.Theaimistoachieveabalancebetweenevidence-basedguidelinesandguidelinesthatarefeasibleinpractice(Groletal.,1995).Anindependentadvisoryboardofexperiencedpractitionersselectsthetopic.Aworkingpartyoffourtoeightfamilyphysiciansisappointed,representingamixofscientificandpracticalexperience.Thegroupanalyzestheliterature,exploresclinicalexperience,andbuildsaconsensusleadingtodraftguidelines.Becausescientificevidenceisoftenlackingorconflicting,thediscussionsareoftenextensive.Only5to10percentofguidelinescanbebasedonscientificevidence(Groletal.,1995).Thedraftguidelinesaresentforcommenttofiftyrandomlyselectedgeneralpractitionersandtoexternalreviewerswhoareusuallyexpertsinthesubject.Afterthisreview,theworkingpartyhastodefenditsguidelinesbeforeacriticalgroupofgeneralpractitionerswithhighacademicandprofessionalstanding.ThedefinitiveguidelinesarethenpublishedinthescientificjournalforDutchfamilyphysicians,andeducationalprogramsaredeveloped.Finally,theimpactoftheguidelinesisassessedbysurveys,andupdatesareprovidedwhennewevidencebecomesavailable.Abouthalfthemembersofworkinggroupsaregeneralpractitionerswithacademicappointments,someofwhomhavedoneresearchonthesubjectoftheguidelines..

TheDutchsystemwouldbepossibleonlyinacountrywheregeneralpracticeresearchan