Family Medicine Final

8/14/2019 Family Medicine Final

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Famil

yC A S E B O O K


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C O N T E N T S

List of familys recent and continuing illness events page 4

Cultural and social environment of the family page 5

Inter-relationships with disease page 6

Family Genogram page 8

Sources of Social Support page 9

Definition of illness page10

Dealing with illness in the family and occupancy of sick role

page11Medical and social resources available in the community page 12

Extent to which household health care needs have been met page 13

Why needs remain unmet page 14

How community efforts to prevent disease and promote health page 15Impinge on the family

Demography, Epidemiology and Psychosocial factors page 16Of illness and disease

Impact of the students presence on the family page 20

Difficulties and satisfactions encountered page 21

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T H E P A C E F A M I L Y

Ms. Cettina Pace, a 59 year old female from Cospicua was chosen to bethe index case for the purpose of the family casebook. Ms. Pace neeVassallo is married to Mr. Charles Pace and together with their daughterreside in a ground floor government housing apartment. The casebookinterview was conducted at their apartment on the 24 th February 2009 andtook the format of a discussion.

At the start of my interview, I asked the household what they understandby family and who is a member of their family. This question was posed asthe elder offspring of Mr. & Mrs. Pace does not reside in the samehousehold. Although the family were disappointed that Roberto (son) hadchosen to stop residing in their household, they still considered him animportant part of their family. Hence this family, consisting of both parents

and their children, is an example of a nuclear family. They explained theirdesire to be an extended family, by having Cettinas mother, Lisa residewith them, however due to their small accommodation Lisa had to beinstitutionalized after the death of her husband George. Forcompletenesss sake, the third type of family model is the single parenttype, where an unmarried, separated or divorced parent lives with his orher children.


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F A M I L Y S T O R Y O F R E C E N T A N DC O N T I N U I N G I L L N E S S E S

Cettina has a past medical history of hypercholesterolemia, hypertension,

hypothyroidism, depression, sciatica and a past surgical history of hysterectomy,pilonidal sinus removal and hernia repair. Cettinas daughter, Tiziana complains thatalthough her mothers flexibility has increased since she started exercising, hermother still finds difficulty in proximal gross movements, like brushing her hair. Herrecent sciatica pain has limited her even more.

Apart from Cettina, the case index, Charles 58, also suffers from hypertension.

Tiziana, 26 suffers from irritable bowel syndrome and Roberto 29 has had no seriousillness or disease.

In this family, Charles and Roberto are smokers. They have both started smoking at ayoung age, and Roberto followed his fathers bad habits. The family was not happy

Roberto started smoking, especially Cettina; however Charles himself could not stopRoberto from being a smoker when he too was a smoker. Charles is disappointed atthe financial burden his habit had on the family. Health wise he believes that it doesnot affect the family, since he does not smoke indoors.

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C U L T U R A L A N D S O C I A LE N V I R O N M E N T O F T H E F A M I L Y

The family seem to be a very closely knit unit who enjoy each others company and

the fact that Roberto has left his parents residence without marriage has hurt thefamily as it is something not usually done in the culture they have been brought upin.

It is very evident that the Pace family has close connections with their extendedfamily, especially on Cettinas side of the family, where a Pace family member visitsher mother Lisa at least once a day. This family is also in close contact with her sister

Josephine and they frequently visit Freddie, Cettinas disabled brother, who lives atDar tal- Providenza. On Charlies side, contact between brothers and sisters wasgreatly reduced when their mother passed away.

Apart from the extended family, Cettina trusts blindly in her GP, however the restof her family seem a bit skeptical to this devout trust of Cettina to the GP.

Regarding gender-roles within the family, there seems to be division of labor with thehouse chores shared by both parents and Tiziana too. However, Cettina states thatonly she is allowed in the kitchen and also claimed to be the main rearer of herchildren, for who she had quit her job. She is now back on the work bench occupyingthe role of an executive officer within the public sector. She considers her job to bevery common. Charles is a senior auditor who considers himself to have a prestigious

job but one that does not give him the authority he would like. Both parents had 11years of schooling to reach A level standard of education. Their children, bothobtained degrees from University with Roberto obtaining a Masters in EuropeanStudies. Education gives one acquisition of knowledge and skills that promote healthand improved health literacy.

This familys educational attainments, occupational status and a parental grossincome of approximately 37000, which is shared among the whole family show thatthis family have a high socio-economic status. This is good news for the family, as anassociation between socio-economic status and health has been recognized forcenturies (Antonovsky, 1967).

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I N T E R - R E L A T I O N S H I P S W I T HH E A L T H A N D D I S E A S E

Social Class

Group I is made up of professionals, Group II of intermediates, Group IIIN of skilled-non manual workers, Group IIIM- skilled manual workers, Group IV semi-skilledmanual workers and Group V unskilled manual workers. The Pace family falls in groupII, since the parents who were the providers of the family fell into this category. Theirchildren are both professionals, and do not depend on their parents any longer,especially Roberto who has moved out of his parents house. During my discussionwith the family, they do not seem to agree that their particular social class had anyeffects on their health. They argued that it depends on who your peers are, and badhabits such as smoking and illicit drug use are common practices within all socialgroups.

Occupation

Regarding their occupations, all the family members argued that their work does notaffect health. They argued that there was no exposure to toxic fumes or dust in theiroccupations. However, when I dug deeper into the matter they did realize that theirwork could be related to ill health. For example the index case, has sufferedtenosynovitis due to keyboard operation. When asked about stress all the familyrelated that their jobs were stressful, and that this stress has caused them anailment. Cettina for example, at times feels mentally drained and starts to panic,which she describes a trigger to her depression. Recently she had a prospect of

promotion in her career, however this extra responsibility and her need to learn newprocedures, stressed her so much, that her family gave her advice not to except thepost as it was not doing her right health wise. Charles explains how this stress affectthe family as a whole, especially since they reside in a small apartment. They arehowever happy that their jobs are effort- rewarding jobs rather than a demandingcontrol type and they agree that the reward they get is in proportion to their hard-work. This motivates them to work hard.

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Environment

They spoke to me about Malta and its polluted, noisy environment as a factor

contributing to ill health. It causes them frustration and this frustration together witha days stressors results in anger many times within the family, the place they feelmost comftable bursting out. Roberto has also suffered from asthma and Tiziana hayfever, which they attribute to the pollution especially in their area, very close toFgura and Marsa, areas known for pollution.

Accommodation

Their small accommodation seems to be their greatest stressor and affects theirhealth the most. They feel they are crowded, and there is lack of privacy. The singledesk in the childrens bedroom was not enough for both Roberto and Tiziana to study

on and an additional desk was put in the parents bedroom for Tiziana to study. Theyexplained how when she was studying, they could not switch on television, and thatthey had to sleep with lights on and their sleep disturbed by shuffling of papers,drawing of chairs, etc. Roberto states, that the only reason he left home was becausehe needed his own space. He said that he feels much better now in his rentedapartment in St. Julians, even though certain luxuries such as having your plateready and clothes done are now absent.

Neighborhood

In addition to the small apartment itself, its neighborhood was no better. They

complained about noise, vandalism and theft, which continued to add to their stressand possibly an attribute to Cettinas depression. However, they are also thankful tosome friendly neighbors who helped the family through cooking and cleaning whenCettina fell ill.

Leisure

Cettina describes how she recently joined a yoga class and how this has improvedher health and quality of life. She described how this active leisure pursuit hasenhanced her fitness, and reduced her cholesterol level. Also the family describesthat they take daily walks and this not only promotes health but also helps to

strengthen their family ties.

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F A M I L Y G E N O G R A M

S O U R C E S O F S O C I A L S U P P O R Tpage 8


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Social support is not important only for assurance of food, warmth and other materialresources, but also equally important to provide love, security and other non-materialresources that are necessary for normal human development (Berkman & Glass,2000). Social support is made up of instrumental, emotional and informational

support. The Pace family unit in the past used to offer instrumental support to all itsmembers in the form of cash. Since both the children started working, the parents nolonger offer instrumental support to their children, who self-support themselvesfinancially. However they still support their children with emotional support and so dothe children support their parents emotionally especially Cettina who needs constantmoral support. The family seems quite reluctant to gain emotional support fromoutsiders. Cettina and Tizianas informational support come from their sportinstructor; however Charles seems to dismiss this information, causing confusionmostly in Cettina who is easily influenced. The family GP is also a source ofinformational support, especially for Cettina who confides in him and is verydependant and strictly obedient to his orders.

The people who provide this social support are the familys social network. I haverealized that this family has a poor social network since they prefer to self supportthemselves. Cettina is the one who would like the most to expand her social structurebut feels constrained by her family who do not approve of this. This poor socialnetwork may be a reason for her depression, because a wealth of informationindicate that good social support buffers the effects of stressful life events and helpsprevent psychiatric disorders (Kawachi and Berckmann, 2001).

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T H E D E F I N I T I O N O F I L L N E S S

For the professional, illness is a mechanical process that went bad, one he has to tryand fix. However, for the patient, an illness is a life-changing event, not only for

himself, but also for his family. The patient may have to change his life-style, give upthings he likes, his body image might change. Hence a normal day of a professionalmay be the life-changing day of the patient and his family. It is easy for a doctor tobecome immune to the sadness surrounding his job, but he must be careful becausehe is dealing with a familys harsh reality and he must not be inhuman.

I asked the family to recount an experience of illness that changed their life. Theytold me about the time when Cettina had her hysterectomy done. They said that theirlife was disturbed. There was nobody to cook, since this is Cettinas role. The childrenwere too young to know how to cook and Charles was busy at work and hospital.Cettina felt guilty that this was happening, she felt as if she had neglected her family.She thanks her neighbors and sisters who used to help at times by cooking for thefamily and see to her children. She found that spirituality also helped her pass

through this difficult time. At the same time, the children were worried and confusedabout what was going on.

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D E A L I N G W I T H I L L N E S S A N DT H E O C U P A N C Y O F T H E S I C K R O L E

The family undergo regular check-ups and encourage and support each other to keepdoctor appointments. Nobody goes alone to the doctor, the patient is alwayssupported.

The next step to deal with an illness is to accept this new state, and not only take themedications required but also to change your lifestyle. This includes a change in diet,where Cettina prepares low salt and cholesterol diets for her family and avoidscertain foods that upset Tizianas gut due to her irritable bowel syndrome. The wholefamily goes for walks. Tiziana also likes to read on the internet about her familysillnesses and conditions to be more informed and this helps her to deal with herfamilys illnesses.

When Cettina said that she felt guilty that she is always sick, this caused a stir in therest of the family members. They told her that with the occupancy of the sick roleone is exempt from responsibility for the incapacity since it is beyond the sickpersons control. This implies that she is exempt from her normal tasks and roles forthe duration of the illness and hence Cettina should never feel guilty when sheoccupies the sick role. However they did add that as an occupant of the sick role,Cettina is duty bound to recognize that being ill is inherently undesirable, and thatshe has an obligation to try and get well. Another duty of the sick person, accordingto this family is to seek competent help and to cooperate in the process of gettingwell.

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L I S T T H E M E D I C A L A N D S O C I A LR E S O U R C E S A V A I L A B L E I N T H EC O M M U N I T Y

Health Centres or Private GPs

Hospital: Outpatients Appointments for checkups regarding state of

chronic diseases such as hypertension, hypercholesterolemia,

hypothyroidism, colonoscopy screening and follow up with

consultation.

Accident and emergency department: for acute conditions

Hospital in-patient

Pharmaceutical services and free medications (Schedule V and the

pink card)

Community nursing and midwifery service

Immunisation services

Speech and Language Department

Child Development and Assessment Unit

Support Line 179

Adolescent Outreach

Programm Ulied Darna

Social Housing Department

Other Institutions e.g., Hospice, Caritas, Sedqa, Meals on Wheels,

Appogg, Richmonds foundation.

A number of support groups e.g. for diabetics, alcoholics, help to quit

smoking.

A number of institutional homes, for the elderly and disabled.

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H A V E T H E F A M I L Y H E A L T H C A R EN E E D S B E E N M E T B Y T H EA V A I L A B L E R E S O U R C E S ?

Cettina, the case index has a very good relationship with her general practitioner,and has been using the same GP as long as she can remember. Cettina states thatshe will never change her GP as he knows not only her past medical, social andfamily history, but he has also developed a good friendly relationship with her. Shecannot understand why her family keeps on insisting she needs second opinions oncertain issues when her GP surely knows it all the best way.

Cettina also gets support from her psychiatrist regarding her depression. Sheexplains how tough it is to open up to this new doctor, especially regarding theseproblems which are a bit of a taboo. Her family however does not understand herfeelings, they argue that the doctor is not a friend; the doctor is a professional and

opening up to any doctor should be as easy.

They also make use of the outpatients department for check-up appointmentsregarding their chronic conditions, however they complain about the bad service, andprefer private clinics, as they trust them better.

The family is entitled to free medications for anti-hypertensive and cholesterol-lowering drugs under the regulations of Schedule V, and they are very grateful as it isvery helpful financially.

The family also makes use of the community nurse. The nurse explains to the family,how Charles should prepare himself for colonoscopy.

The family also made use of Hospice, when Cettinas father was dying with prostatecancer. The family also needed the resources of Caritas when their son was caught inpossession of illicit drugs.

They also needed to use the service of the Bormla home for the elderly for Cettinasmum, since they did not have space to keep her at their place and Dar tal-Providenza, for Freddie, Cettinas brother.

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Why needs remain unmet

Cettina clearly needs more help regarding her depression and her psychiatrist doesnot seem to be helping her enough, partly due to her lack of trust in him and herenvisagement of her condition as a taboo. An association, for example theRichmonds foundation would be of great help to her. Her thyroid problem, however,

makes her lethargic and she finds it hard to cope with her life already, and sheargues that she cannot cope with another activity in her life.

Also, it would be very helpful for a directory of all the medical and social servicesavailable in Malta to exist.

Charles suggested that it would be a very good idea if a child care centre existed forthe children of those who have a sick parent or a parent in hospital.

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H O W T H E E F F O R T S O F T H EC O M M U N I T Y T O P R E V E N TD I S E A S E A N D P R O M O T E H E A L T H

I M P I N G E O N T H E F A M I L Y

The health promotion department does a very good job according to this family.Charles say that the promotional material do have potential to influence people, buthe himself has no will to change, and no anti-smoking promotional material will makehim quit smoking. The family appreciated the effort of the health promotiondepartment and the variety of media it uses for promotion, but they all agreed that atelevision advert is the most effective.

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D E M O G R A P H Y ,E P I D E M I O L O G Y A N DP S Y C H O S O C I A LF A C T O R S O F I L L N E S SA N D D I S E A S E


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H Y P O T H Y R O I D I S M

Hypothyroidism is more common in woman, with 1.5- 2% of woman sufferingfrom this diseases. The incidence of hypothyroidism increases with age: amongpersons older than 60 years of age 6% of women have laboratory evidence of

hypothyroidism where TSH levels are twice normal (Ferri: Ferris clinical advisor2009, 1st ed). Patients of Caucasian origin as my case study is are more affectedthan people of black descent. Cettina had no previous family history of thedisease and no associated autoimmune disease. The hypercholesterolemiaexperienced by Cettina is most probably due to her ongoing hypothyroid disease.Depression is one of the major symptoms associated with hypothyroidism.Haggerty states that 100% of patients presenting with severe hypothyroidism arefound to have concurrent depression as was the case of the index patient(Borderline Hypothyroidism and depression, Haggerty JJ & Prange AJ, 1995).

The biopsycosocial model represents a health concept. It depicts a treatmentparadigm that acknowledges the contribution of biological, psychological andsocial factors (The need for a new medical model: a challenge for

biomedicine, Engel, 1972). Hypothyroid has been successfully treated in manycases by the biomedical treatment such as drugs. For example, Cettinashypothyroid is well controlled from her levels of TSH and T3 and T4. However,symptoms sometimes seem to recur even if she is well controlled. This has beenwell documented in the literature (The diagnosis and management ofhypothyroidism, Roberts CGP & Ladeson PW). If psychological and social factorsare also dealt with, this chronic condition will be dealt with in a much better way,and may control the disease better than with merely the biomedical model oftreatment (The biopsychosocial model and hypothyroidism, B.T. Brown etal., 2005).

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H Y P E R T E N S I O N

Hypertension is also a disease that increases in its prevalence with age, and thistime the races of African descent have a higher prevalence f hypertension thanthe Caucasian race. A few other personal characteristics influence hypertension.

These include concurrent diagnosis of diabetes mellitus, the presence of obesity,lack of physical activity(present in this family before the diagnosis ofhypertension) and excessive use of sodium and alcohol (The prevalence anddemographics of hypertension, Davidyan, A). Lisa, Cettinas mother alsosuffered from hypertension, as seen in the genogram. In the case of Charles, hisfather Francis and brother Joe have also suffered from hypertension. The geneticfactors contributing to hypertension have not yet been found.

The role of psychosocial factors such as: type A behavior, depression and anxiety,are well documented in the etiology of hypertension (Circulation, Krantz DS etal, 1987). However there are some conflicting studies (The relationship ofpsychosocial factors to coronary artery disease in Framingham study I:methods and risk factors, Haynes CG et al, 1978). Biologically it is plausible

that psychosocial factors may interact with hypertension. Stress may activate thesympathetic nervous system, leading to increased cardiac output,vasoconstriction, arterial pressure elevation, impaired endothelial faction andplatelet activation (Effects on psychological and social factors on organicdisease: a critical assessment of research on coronary heart disease,Krantz DS, 2002).

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E V A L U A T I O N


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T H E S T U D E N T S I N F L U E N C E O NT H E F A M I L Y

Cettina Pace is my mums sister, and hence I am part of their extended family. As Ihave already said, the Pace family especially Cettina are very close to their extendedfamily, hence during the interview we were discussing things as if we were talkingnormally, and they definitely did not feel like they were put in any uncomftable orunnatural situation.

During my interview, I believe I made them more aware that health is not just theabsence of disease, but as the World Health Organization describe it: a state ofcomplete physical, mental and social well being.

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D I F F I C U L T I E S A N DS A T I S F A C T I O N S E N C O U N T E R E D

I felt quite uncomftable asking Cettina about her mental health condition, whichfor her is a taboo, and rarely mentioned even in the family.

The satisfactions were plenty: I was well accepted in the family, and they triedtheir very best to help me with all the information I needed. During thepreparation for the interview, I realized, that there was much more to familymedicine than just the biomedical model of curing a disease, and that thebiopsychosocial factor was much more relevant. In order to treat the chronicconditions with this model, the case index should be asked questions that point tohis and his familys biopsychosocial being.


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Family Medicine Final