Nino Kiknadze MD, PhD Georgia Francesco Carelli MD, MSc, PhD Italy

1. Introduction to GP/FM as a specific medical discipline. Principles of Family Medicine: Continuity, comprehensiveness, coordination of care Nino Kiknadze MD, PhD Georgia Francesco Carelli MD, MSc, PhD Italy

2. Objectives We try to give an example of blended learning for teachers in family medicine - how to transform minimum core curriculum topic N4 to E-learning module. • The purpose of the course is to acquaint trainees with the essence of family medicine; to demonstrate comprehensive approach within this specialty and show specific qualities of family physicians in problem solving related to prevention and management of acute and chronic health problems as well as continuity and coordination of care • Target auditory - Undergraduate Students –V or VI year

3. Learning Methodology - blended learning 1. E-learning - Case discussion 20-30min 2. Task groups - session 35 min 3. Traditional Lecture 10-15 min • Ask students to work with E-case independently, • and then arrange traditional classroom session

4. 1. E-Casereal case from primary health care practice • Patient: 56 y. old Caucasian man. He is a new patient in your office. • Known medical history: poorly controlled arterial hypertension for last 6 y, medication: Enalapril 10 mg. hydrochlorothiazide 25mg. • Patient lives with his wife. He is a cook in a big restaurant and his job is very important for him. Smoking 5-6 cigarettes day, not thinking that it is harmful, physically inactive. • Examination: Arterial blood pressure 160/90mm.Hg, pulse rate -70. BMI 25.3. • Past medical history: not significant.

5. What kind of information is important to collect about this patient? Possible answers • Family history • Heart pain • Cough • Previous medication for hypertension • Eating habits • Another current medication for any problem • Last lab test results – lipid profile, blood glucose • Screening history? • Urinary frequency/difficulties?

6. Manage this patient: including short term and long-term management plan Possible answers Cardiovascular risk assessment (including lab and instrumental tests) Healthy life style promotion, including eating habits, exercise and smoking cessation. Add new antihypertensive or increase Enalapril Secondary Prevention according to age and sex ? Finding resource to help patient with smoking cessation (groups or trained doctor)?

7. Example of “check your answer”

8. Do you want to add something to the management plan? At this point, the student has the possibility to add more options to his/her previous management plan

9. Check your answers and additional information (1)short term and long term management (Student can see in neighbour spaces his/her own answers and this list as shown in slide N8) • Cardiovascular risk assessment - done and statin added to treatment plan. Monitoring after 2 months • For arterial hypertension -Enalapril 10mg added. Monitoring after 2 months • Diet, exercise, smoking cessation –by trained doctor. Arrange next visit according to smoking cessation plan. • Urinary tract obstruction complaints - PSA - 35ng/ml (normal value < 3.5ng/ml) and prostatic US – enlargement • Colonoscopy or occult bleeding test – planned

10. Additional Information • Multiple core biopsies of prostatic gland performed under transrectal ultrasound guidance; cytology: found prostatic adenocarcinoma in 2 from 16 samples from one lobe. No metastatic damages found before or during surgery. • Radical prostatectomy performed. One week after Urological Surgery (2 days after discharge from hospital) the patient applied with leg swelling and pain. You confirmed diagnosis of DVT and found, that the patient did not receive DVT prophylaxis after surgery.

11. Task for independent work Think about reasons for this mistake and ways to avoid this kind of complications when this patient received medical care in different places and specialists.

12. Additional information • Now patient is under monitoring of family doctor and urologist. • Arterial hypertension and cholesterol are under control, PSA < 0.01 during last 1,5 y. • Patient improves his eating habits and physical activity, smoking cessation failed after 1 year and now he tries to stop again.

13. Small group – 15min Presentation and Discussion 20 min Lecture-10 min

14. Group working Ask what connections and similarities can they find between small group exercise and E-Case. • Distribute pictures of different heroes from one movie • Than show full episode of film https://www.youtube.com/watch?v=qNseEVlaCl4 • OR - Part from painting and than show full picture

15. Introduction to FM/GP as a specific medical discipline. Principles of Family Medicine: Continuity, comprehensiveness, coordination of care

16. THE EUROPEAN DEFINITION OFGENERAL PRACTICE / FAMILY MEDICINE • General practice/family medicine is an academic and scientific discipline with its own educational content, research, evidence base and clinical activity, and a clinical specialty orientated to primary care

17. OVERVIEW OF THE DEFINITION 6 Core Competencies 1. Primary Care Management 2. Person Centred Care 3.Specific Problem Solving 4. Comprehensive approach 5.Community Orientation 6. Holistic Modelling 11 Characteristics a. First contact / all health problems b. Care co-ordinator + advocacy c. Person centred approach d. Doctor-patient relationship / consultation process e. Longitudinal continuity f. Decision making based on prevalence g. Early undifferentiated stages h. Acute & Chronic management i. Health & Wellbeing j. Responsible for health in the community k. Bio-Psycho-Social + culture and existential

18. WONCA TREE (revised 2011)

19. Principles of Family Medicine: Continuity, comprehensiveness, coordination of care Includes the ability: • to manage simultaneously multiple complaints and pathologies, both acute and chronic health problems in the individual; • to promote health and well being by applying health promotion and disease prevention strategies appropriately; • to manage and co-ordinate health promotion, prevention, cure, care and palliation and rehabilitation.

20. Principles of Family Medicine: Continuity, comprehensiveness, coordination of care is responsible for the provision of longitudinal continuity of care as determined by the needs of the patient.

21. Principles of Family Medicine: Continuity, comprehensiveness, coordination of care • makes efficient use of health care resources through co-ordinating care, working with other professionals in the primary care setting, and by managing the interface with other specialties taking an advocacy role for the patient when needed.

22. Sir William Osler (1849 - 1919) “The good physician treats the disease; the great physician treats the patient who has the disease”

23. Introduction to FM/GP as a specific medical discipline. Principles of Family Medicine: Continuity, comprehensiveness, coordination of care Source: THE EUROPEAN DEFINITION OF GENERAL PRACTICE / FAMILY MEDICINE WONCA EUROPE 2011 Edition