Orientation Course

THE
PHILIPPINE ACADEMY OF FAMILY PHYSICIANS,

INC.
___________________________________________________
PROCEEDINGS OF THE ORIENTATION

COURSE IN FAMILY MEDICINE
Contributors:
1. Zorayda Leopando, M.D.
2. Alejandro Pineda, Jr.,M.D.
3. Nelson Rodriguez, M.D.
4. Isabelita Samaniego, M.D.
Editors:
1. Rosalia Fabia-Bugayong, M.D.
2. Alejandro Pineda, Jr.,M.D. (1999)
2244 TAFT AVENUE, MALATE, MANILA 1004

TEL. 516-2900
TEL./FAX NO. 254-5646
TABLE OF CONTENTS
I. Family Medicine: History And

Perspective
II. Family As A Unit Of Care
III. Family Life Cycle
IV. Impact Of Illness On The Family
V. Tools In Family Assessment
1
___________________________________________________
THE
INC.
___________________________________________________
FAMILY MEDICINE:
HISTORY AND PERSPECTIVE
2
FAMILY MEDICINE: HISTORY & PERSPECTIVES
ZORAYDA E. LEOPANDO, MD
HISTORICAL BACKGROUND
A. INTERNATIONAL PERSPECTIVES
There was a time when health care was provided by general practitioners right in
the patients homes. The emergence of the different clinical specialties and
subspecialties that focused on the different organ systems or diseases came about with
increased body of knowledge in medicine. Progress in technology and medical
know-how led to the establishment of medical centers and health care complexes ,
which eventually became the locus of health care and services. At the limelight were
specialties and subspecialties. It has been said that the art of general practice was not
emphasized in medical education and clinical practice. Medical graduates wanted to
become specialists as the emerging role models in medical institutions were the
specialists. Medical care naturally evolved into an organ or system focused practice
leading to a fragmented and depersonalized care. Curative medicine was given more
emphasis over preventive medicine. Health care was said to have become
fragmented, depersonalized and costly.
A series of events in the 1960s led to the emergence of Family Medicine.
1962 The WHO Expert Committee on Professional and Technical

Education and Medical Auxiliary Personnel met in Geneva.
1. There was a need to train family doctors to serve as physicians

of first contact with the patient
2. That every medical student's training should include exposure to
family practice.
1962 Folsom Committee Report (National Health Council and APHA)
1. Every individual should have a personal physician who is a

central point for integration and continuity of all medical and
medically related services to his patient.
2. Every hospital should have a service for the personal physician
who has a staff appointment in one or more accredited
hospitals.
1966 Millis Commission Report (Citizen's Commission on Graduate

Medical Education and AMA).
1. "It is time for decisive action to increase greatly the number of

physicians who will devote their professional careers to the
highly competent provision of comprehensive and continuing
medical service.
2. There should a specialty board, certification examination and
diplomate status for (primary) physicians highly qualified in
comprehensive care."
1966 Willard Report (Council on Medical Education, AMA and Ad Hoc

Committee on Education for Family Practice)
1. "The opportunity for specialty board certification is essential for

those properly prepared for family practice. Board certification
is the only appropriate recognition for physicians who have
invested the time and effort necessary to complete prescribed
training program and who have demonstrated their competence
in this important field of medicine. Certification is necessary to
provide status to the field and to reward those who have
prepared themselves in suitable manner. Both status for the
field and regard for the individual is essential to attract young
physicians to careers in Family Practice."
3
Together, the reports served as impetus for the development of Family Practice.
Each chronicled the progressive diminution of the generalist physician trained and
committed to the practice of continuing , comprehensive and personalized health care.
Thus, the concept of Family Medicine was introduced to fill-in the gap between medical
care and the needs of the people.
The above-stated reasons led to a meeting of general practitioners and the

formation of a specialty organization for general practitioners.
The accepted name for the World Organization of National Colleges,

Academies and Academic Associations of general Practitioners / family
Physicians are WONCA. Its short name is World Organization of Family Doctors. It
was formally inaugurated at the 5 th World Conference held in Melbourne, Australia in
1972. Comprising over 50 Member Organizations from more than 40 countries, full
membership is available to national colleges, academies or organizations concerned
with the academic aspects of general family practice. General practitioners / family
physicians can become part of this organization through direct membership. Its
objective is to improve the quality of life of peoples of the world through fostering and
maintaining high standards of care in general practice / family medicine.
WONCA:
1. provides a forum for exchange of knowledge and information between
member's organizations.
2. encourages and supports the development of academic organizations
of general practitioners / family physicians
3. represents the educational, research and service provision activities of
general practitioners / family physicians before other world
organizations and forums concerned with health and medical care
In 1979, the WONCA arrived at a definition of what Family Medicine is during its
Regional Conference held in Manila, Philippines.
Family Medicine is a discipline of Medicine with distinct core knowledge &

characteristics of care, which refers to individuals, family and community, and
functions within economic, cultural and social environments & resources.
The characteristics of care given by family medicine are:
a. Primary first contact care at ambulatory, Emergency Room &

home
b. Continuing chronologically (womb to tomb);
geographically (home, clinic & hospital);
Interdisciplinary (coordinates different disciplines in
medicine & health & non-health agencies);
interpersonal (involvement of family in care,
doctor-patient relationship)
c. Comprehensive ecological factors: social, cultural, economic
educational, etc.
d. Aspects of Care
Prevention - all levels of prevention, with emphasis on

health education.
Curative - relieve symptoms, early diagnosis & treatment.
Rehabilitative - assist patient to go back to society.
B. PHILIPPINE PERSPECTIVES:
Growth of Family Medicine in the Philippines:
1961 Philippine Academy of General Practitioners was organized.

Dr. Ramon Angeles, Founding President wrote its commitment:
offer a continuing medical education as the basis of good
medical practice and patient care;
to promote the standards and quality of medical care by
the general practitioners and family physicians;
to recognize the importance of providing a family
physicians for every family; and,
promote closer and healthy professional and fraternal
relations among the GPs and the Specialists as each is
as important in the proper handling of the sick
4
1970 Recognition as a Specialty Society by Philippine Medical
Association (PMA)
1972 Changed name to PAFP (Philippine Academy of Family

Physicians, Inc.)
recognized non-profit, non-stock corporation by the
Securities and Exchange Commission (SEC)
Vision: The PAFPaiming to provide every Filipino a
family physician to attain optimum family
health
Mission: * optimum family health and quality of life
through
Family Wellness Program
opportunities for high standards of family
medicine education
Family Medicine as a required
undergraduate course
Family Medicine Residency Training
program relevant to changing needs
comprehensive, accessible and relevant
continuing medical education program
1974 First three-year residency training program was established

by UP-PGH
1979 a. First Specialty Board qualifying examination was given

b. Department of Health (DOH) recognition as a specialty
1983 Research Contest started
1986 an accredited three year residency training program was

established in the Santo Tomas University Hospital (STUH)
1987 Recognition of PSTFM (Philippine Society of Teachers

in Family Medicine) as an academic society by APMC
(Association of Philippine Medical Colleges)
recognized as a non-profit, non-stock corporation by the
Securities and Exchange Commission (SEC)
organized to attend to educational issues in Family
Medicine
conducts teacher training activities and intensive
workshops
published the Core Curriculum for Family Medicine
Residency Training Program together with the PAFP and
WONCA
1990 Recognition of Family Medicine as a specialty by Medicare
1997 Recognition by PMA as the mother specialty society in the

field of Family and Community Medicine
FAMILY MEDICINE IS A SPECIALTY

Prof. Ian R. McWhinney, one of the fathers of Family Medicine presented the four
criteria for considering Family Medicine as a specialty:
1. Distinguishable body of knowledge

2. Unique field of action
3. Active area of research
4. Training which is intellectually vigorous.
These criteria make Family Physicians at par with other specialists.
5
1. DISTINGUISHABLE BODY OF KNOWLEDGE
body of knowledge is different

integration of biological, clinical, behavioral sciences
its curricular framework indicates that elements of traditional clinical
disciplines (such as Medicine, Surgery, Obstetrics, Pediatrics & Psychiatry)
are held together by interdisciplinary features.
emphasis on prevention, modern epidemiology, psychological medicine,
social & cultural factors in health care & delivery system
attention physician to the person is of profound importance.
2. UNIQUE FIELD OF ACTION
family-oriented health care

encompasses all ages, both sexes each organ system, every disease entity,
wellness. Patients' cases are undifferentiated & not categorized.
3. ACTIVE AREA OF RESEARCH
Family Medicine as an academic discipline is strengthened by research.

Areas of interest include: - clinical problems, health care delivery, family,
family practice approach.
* Clinical Problems: Epidemiology of Common diseases

Natural history of diseases
Screening for diseases
Disease prevention & health promotion
Therapy of common health problems
*Health Care Delivery: Provider characteristics

Utilization of health services
Practice outcomes of health care
alternatives
Cost effectiveness of care
*The Family in Family Medicine Family Epidemiology

Impact of illness on the family
Effect of family on illness
Family stress & life event
Family resource utilization
*Family Practice Approach Anticipatory Guidance

Decision Analysis
Family Therapy
Patient education
Family Medicine Education
4. TRAINING WHICH IS INTELLECTUALLY VIGOROUS
strong emphasis on continuity and experience in family care

Behavioral Science
Community Medicine
Inter-departmental cooperation
regularly reviewed & revised to make it relevant to the changing conditions in
society
committed to lifelong continuing medical education (CME).
Family Medicine residency program is a 3-year program, which covers different

rotations. Methods of instructions include supervised patient care, conferences and
group discussions, research, family visits and community immersions.
By the end of the training, the physician should be able to provide first contact,
continuing and comprehensive care to members of families, taking into consideration
the socio-cultural and economic factors. Specifically, the graduate of residency
program should be able to gather, organize and record data; to assess data and
manage health problems in surgical and medical cases and to perform diagnostic
procedures.
6
The bases of these competencies are experiences of Family Physicians and
representative Family Physicians all over the country in coordination with
representatives of other specialty groups defined these.
Projected Programs include: stronger Family Health Care, Emergency Medicine

and Community Health. Individualization of electives is based on interest of trainees
and needs of areas. There should also be Dispersal Program, and Faculty
Development.
FAMILY MEDICINE:
As an academic discipline, Family Medicine encompasses a distinct body of
knowledge appropriate to the needs of a changing society. It is centered on the family
as a basic social unit. It is not only disease-oriented but health-oriented which
emphasizes on the importance of disease prevention, health maintenance and curative
medicine.
FAMILY PRACTICE:
It is the art of how the body of knowledge is dispersed to the community. It refers
to care that is primary, continuing, comprehensive, preventive, curative, referring to
individuals, their family and community relationship. It encompasses ambulatory care,
home care and appropriate hospital care. It acknowledges the importance of practice
management.
FAMILY PHYSICIAN
The medical practitioner, who implements the principles of the discipline and
provides health care in specialty, is a family physician. The roles played are: healer,
teacher, advocate, manager, scientist, counselor and friend.
CONTINUING MEDICAL EDUCATION FOR FAMILY PHYSICIANS IN

THE PHILIPPINES
Medical Education is a continuum, which starts in medical school, through
residency and into lifelong continuing medical education. In the Philippines, Family
Medicine has a strong residency and Continuing Medical Education (CME) programs for
physicians. The Philippine Constitution has included articles on Family development
and comprehensive health care, which are issues relevant to Family Medicine. The
Dept. of Health has called on changes in Medical Education to make it more relevant to
the health needs. The World Federation of Medical Educators and APMC has called for
introduction of care with generalist's approach for medical students.
The clinical discipline with generalist's approach is Family Medicine. Except for
UST, Family Medicine undergraduate course is integrated with Community Health. In
institutions where there is Family Medicine programs, some of our colleagues
interchange Public Health, Community Health and Family Medicine.
There is a need for as distinct Family Medicine Course for the following reasons:
1. In response to the need for medical graduates to have generalist approach.

2. Family Medicine is the course that can integrate the different disciplines in
Medicine as shown by the curriculum framework.
3. All medical students should have exposure in Family Medicine so that after
graduation, they will understand the discipline better, making them better
prepared in the future practice as they work with different disciplines.
4. All medical students should be exposed to different specialties so they will have
different perspectives for career option.
CONTINUING MEDICAL EDUCATION

The Academy is the first specialty society that requires member's rectification
through CME. At present, there are regular scientific seminars in Metro Manila and in
the 35 chapters all over the country. There are 4 modules in Manila, one midyear
Convention, Chapter modules and Orientation Course in Family Medicine. There is also
a Quarterly Journal and Proceedings of Annual Postgraduate Course. Topics
discussed are based on 1987 survey of Family Physicians. Most of the strategies are
interactive programs. Family doctors, especially those practicing in remote areas may
7
not be able to participate in the modules because it is impossible to leave their practice.
What is suggested is home or self-study technique. The problems anticipated in this
regard are mainly on logistics and human resources.
FAMILY MEDICINE RESIDENCY

Family Medicine residency program is a 3-year program, which covers different
rotations. Methods of instructions include supervised patient care, conferences and
group discussions, research, family visits and community immersions.
By the end of the training, the physician should be able to provide first contact,
continuing and comprehensive care to members of families, taking into consideration
the socio-cultural and economic factors. Specifically, the graduate of residency
program should be able to gather, organize and record data; to assess data and
manage health problems in surgical and medical cases and to perform diagnostic
procedures.
The bases of these competencies are experiences of Family Physicians and

representative Family Physicians all over the country in coordination with
representatives of other specialty groups defined these.
Projected Programs include: stronger Family Health Care, Emergency Medicine and
Community Health. Individualization of electives is based on interest of trainees and
needs of areas. There should also be Dispersal Program, and Faculty Development.
8
___________________________________________________
THE
INC .
___________________________________________________
FAMILY AS A UNIT OF CARE
9
FAMILY AS THE UNIT OF CARE
NELSON RODRIGUEZ,MD
1987 PHILIPPINE CONSTITUTION
ARTICLE II SECTION 12 :
The state recognizes the sanctity of family life and shall protect and strengthen
the family as a basic autonomous social institution.
ARTICLE II SECTION 15.
The state shall protect and promote the right to health of the people and instill
health consciousness among them.
ARTICLE XIII SECTION 2.
The state shall adopt an integrated and comprehensive approach to health

development, which shall endeavor to make essential goods, health and other
social, services available to all the people at affordable cost.
ARTICLE XV SECTION 1:
The state recognizes the Filipino Family as the foundation of the nation.
Accordingly, it shall strengthen its solidarity and actively promote its total
development.
DEFINITIONS OF THE FAMILY
SOCIOLOGIC VIEWPOINT - enduring social form in which a person is

incorporated
BIOLOGIC VIEWPOINT - genetic transmission unit
PSYCHOLOGIC VIEWPOINT - matrix of personality development and the

most intimate emotional unit of society.
Parsons and Bales, 1955:
That social unit whose primary tasks are socialization of children and the
stabilization of adult personalities.
Rogers, 1973:
The family is a semi-closed system of actors occupying inter-related

positions defined by society of which the family system is a part as unique
to that system with respect to the role content of the positions and to the
ideas of kinship relatedness.
Murdock , 1965:
The family is a social group characterized by common residence, economic

cooperation, and reproduction.
Ransom and Vandervoort, 1973:
Significant group of intimates with a history and future.
Gordon, 1978:
The family is the unit made-up of individuals a person is related to by blood

or marriage and to whom he/she feels ties of obligation.
10
Smilkstein, 1978:
Adult partners with and without children and single parents with children
who function in a setting where there is a sense of home, and who have an
agreement to establish nurturing relationships.
Berman, 1978:
A small social system made up of individuals related to each other by

reason of strong reciprocal affections and loyalties and comprising a permanent
household ( or cluster of households) that persists over years and decades.
Terkelson and coworkers, 1980:
A small social system made up of individuals related to each other, biologically or

by reason of strong affections and loyalty, that comprises a permanent
household (or cluster of households) and persists over decades. Members enter
through birth, marriage or adoption and leave by death; roles of members change
over time and through the history of the group.
United Nations:
A group of people related by blood, marriages or adoption, which live together in

one household.
THE FILIPINO FAMILY
CHARACTERISTICS:
1. closely knit
2. bilaterally extended
3. strong family orientation
4. authority is based on seniority / age
5. externally patriarchal, internally matriarchal
6. high value on education of members
7. predominantly Catholic (80%) of population
8. child-centered
9. average number of members is 5 (NEDA statistics)
10. environmental stresses: economic, political, urbanization and
Industrialization / urbanization, health problems
THE FAMILY AS A VERY SPECIAL UNIT
1. Lifelong involvement
2. Shared attributes
genetics - physical and psychological
developmental - shared home, lifestyle and social activities
3. Sense of belonging
security / defense against a potentially hostile environment
companionship
4. Societal expectations
sense of responsibility towards members
sense of responsibility towards others
basis of affection / care
11
5. Built-in problems
generation gap
dependence of members
emotional attachment / involvement
6. The family endures inspite of problems

resource utilization
authority
individual sense of responsibility
FAMILY STRENGTHS:
A. The ability to provide for the family's needs.
PHYSICAL Space management, nutritionally balanced meals
family's general health status
EMOTIONAL Helping family members recognize and develop their
capacity
for sensitivity to each other's needs
SPIRITUAL Sharing of basic beliefs and cultural values
CULTURAL Sharing of basic beliefs and cultural values
B. Child-rearing practices and discipline:
The capability of both parents to respect each other's views and decisions on
child-rearing practices
If a single parent, the capacity of the single parent to be consistent and
effective in raising the child or children.
C. Communication:
the ability to communicate and express a wide range of emotions and feelings
both verbally and non-verbally.
D. Support, Security & Encouragement:

The capacity of the family to provide its members with feelings of security and
encouragement
Balance in the pattern of family activities
.
E. Growth - Producing Relationships:
the family's ability to maintain and build friendships and relationships in the
neighborhood.
F. Responsible Community Relationships:

the capacity of family members to assume responsibility through participation
in social, cultural or community activities.
G. Self-help & Accepting Help:

family members' ability to seek and accept help when they think they need it
H. Flexibility of family functions and roles:
family members' ability to "fill in" for one another during times of illness or
when needed.
I. Crisis as a means of growth:

family members' ability to unite and become supportive during a crisis or
traumatic experience.
J. Family unity, Loyalty and Intra-family Cooperation:

family members' ability to recognize and use family traditions and rituals that
promotes unity and pride.
12
FAMILY HEALTH CARE
Taking care of all individuals in the family on a one by one basis

Dealing with the family as object of management
Influencing family members to change factors affecting each individuals
health
FAMILY AS THE UNIT OF CARE
1. THE FAMILY AS THE SOCIAL CONTEXT FOR HEALTH CARE

transmission of infectious / communicable diseases
health behavior requirements in the unit
resource utilization / source of support
health and illness definitions
health decisions / approaches and strategies
2. THE PATIENTS PROBLEM IS THE FAMILYS PROBLEM

Doherty and McCubbin, 1985: Important ways in which the family plays a
role in the health of its members:
a. health promotion / maintenance and illness / injury prevention
b. coping with stressful life events
c. family based health and illness appraisal
d. family interaction and level of functioning in response to specific illness
e. help seeking or deciding on the issue of seeking medical support
f. family adaptation / coping with illness including care giving, strict
adherence to prescribe treatment and lifestyle modification
3. THE FAMILY IS THE GREATEST ALLY IN THE PATIENTS TREATMENT

90% of cases are ambulatory / out-patient consultations with home
confinement / prescriptions
4. PRESENCE OF THE FAMILY IN THE INTERVIEW / CONSULTATION

familys influence on the patients personality, values, beliefs and experiences
familys influence on the physicians personality, values, beliefs and
experiences
FAMILY STRUCTURE:
1. NUCLEAR:
Parsons and Bales, 1955:
The members of the nuclear family, consisting of parents and their still
Dependent children, ordinarily occupying a separate dwelling not shared with
members of the family of origin / orientation of either spouse
The household is in the typical case economically independent, subsisting in

The first instance from the occupational earnings of the husband / father.
2. EXTENDED FAMILY
unilaterally extended
bilaterally extended
This family includes three generations; family centered; lives together as a

Group and through its kinship network provides support functions to all members.
13
3. SINGLE PARENT FAMILY
children < 17 years of age living in a family unit with a single parent,
Another relative, or a non-relative
may result from the loss of spouse by death, divorce, separation, desertion
out-of-wedlock birth of a child
from an adoption
One parent is working outside the Philippines (OCWs, DHWs, etc.)
4. BLENDED FAMILY
includes step-parents and step-children

caused by divorce, annulment with remarriage and separation
5. COMMUNAL / CORPORATE FAMILY
grouping of individuals which are formed for specific ideological or societal

purposes
considered as an alternative lifestyle for people who feel alienated from the
predominantly economically oriented society
vary within social context
highly formalized structures: e.g. Amish community in Lancaster
County Pennsylvania
loosely knit groups: e.g., Sta. Cruz mountains near Boulder Creek in
California
BASIC AREAS OF FAMILY FUNCTION
1. BIOLOGIC - reproduction
- Child rearing / caring
- Nutrition
- Health maintenance
- Recreation
2. ECONOMIC - provision of adequate financial

Resources
- Resources allocation
- Ensure financial security of
Members
3. EDUCATIONAL - teach skills, attitudes and skills

relating to other functions
4. PSYCHOLOGIC / AFFECTION - promotes the natural

development of personalities
- Offer optimum psychological
Protection
- Promotes ability to form
relationship with people
in the family circle
5. SOCIO-CULTURAL - socialization of children

- Promotion of status and
Legitimacy
14
FAMILY RELATIONSHIP, INTERACTIONS
AND
EFFECTS ON HEALTH CARE
A. ORDINAL POSITION ( DIFFERENCES IN BEHAVIOURS)
1. FIRST BORN - generally persevering

serious
more responsive to adults
achievement oriented
2. MIDDLE CHILD - optimistic

sociable
aggressive
competitive
occasionally manipulative
3. YOUNGEST - demanding
outgoing
occasionally narcissistic
by nature are affectionate
B. PARENT - CHILD INTERACTION / FAMILY RELATIONSHIP
C. FAMILY SOCIAL CLASS PATTERNS
1. UPPER CLASS - much more closely-knit

- Greater concern for maintaining family
Name and prestige
2. MIDDLE CLASS - believes in hard-work, initiative,

Independence, responsibility, economic
Security and self-improvement through
Education / schooling
3. LOWER CLASS - sees life as a continual struggle for

Survival
- Resigned to a life of frustration and
Defeat
D. FAMILY SET-UP
1. DEMOCRATIC - parents respect their childs decisions and

Ideas
- Understanding and permissiveness prevail
2. AUTHORITARIAN - unquestioned obedience conformity to

Parental guidance
- Pattern of punishments than praise
- Patients with low self-reliance,
- Suspicious of adults
- Stand poorly in stressful situation
- Become hostile with pain or
Discomfort
15
___________________________________________________
THE
INC.
___________________________________________________
FAMILY LIFE CYCLE
16
FAMILY LIFE CYCLE
ISABELITA SAMANIEGO, MD
Families go through developmental processes.
THE FAMILY LIFE CYCLE:

represents composite of the individual developmental changes of family
members
shows the evolution of the marital relationship
Presents cyclic development of the evolving family unit.
WHY DO WE STUDY THE FAMILY LIFE CYCLE?

It provides a predictable, chronologically oriented sequence of events in
family life with which family physicians and other health professionals are
already familiar
It involves a sequence of stressful changes that requires compensating or
reciprocal readjustments by the family if it is to maintain viability.
Events of Family Life Cycle can be related to clinical events and to health
maintenance of the family
TWO LEVELS OF ORDERS OF MAGNITUDE OF CHANGE
1. FIRST ORDER CHANGES

INVOLVE INCREMENTS OF MASTERY AND ADAPTATION
a NEED TO DO something new
do not involve change in the main structure of the family
do not involve a change in an individuals identity and self-image
additions to existing state of the individuals self and family
Tasks that must be accomplished by the family and family members working
within a stage of the Family Life Cycle. E.g.: A change that is present when
a family moves to a new residence.
2. SECOND ORDER CHANGES

INVOLVE TRANSFORMATION OF AN INDIVIDUALS STATUS AND
MEANING
a NEED TO BE something new
Change in the very basic attributes of the family system
Change in the role and identity of family members
Occur between stages of the Family Life Cycle
One characteristic intergenerational connectedness. E.g.: A change that is
present when a family moves into the stage of the birth of the first child.
Husband becomes the father and wife becomes the mother of a dependent
sibling.
STAGES OF THE FAMILY LIFE CYCLE

1. Unattached Young Adult
"Between Families." It is the start of the family life cycle wherein the unattached
young adult has come to terms with the family of origin. At this stage, the young adult
formulate personal goals in developing as an individual, including forming a new family.
2. The Newly Married Couple
"The Joining of Families through Marriage" is very true in the Philippines; thus
Filipino families are bilaterally extended. This is the transition stage of the couple from
their lives as an individual to life as couple.
17
STAGES OF MARRIAGE
STAGES EMOTIONAL ISSUES STAGE CRITICAL TASKS
1. Honeymoon stage
(0-2 years) Commitment to the a. Differentiation
family origin
from
marriage
b. Making room for spouse
with family and friends
c. Adjusting career
demands
2. Early Marriage Stage
(2-10 years) Maturing of Relationship a. Keeping romance in the
marriage
b. Balancing separateness
and togetherness
c. Renewing marriage
commitment
3. Middle Marriage Stage Post-Care Review and a. Adjusting to mid-life
(10-25 years) changes
b. Renegotiating
relationship
c. Renewing marriage
commitment
a. Maintaining couple
4. Long-Term Marriage Farewells and Planning functioning
Stage
(25 + years) b. Closing or adapting
family home
c. coping with death of

spouse
3. The Family with Young Children
This stage starts with pregnancy for the first child to emergence of adolescents. The
coming of children defines a new family status, as the wife becomes the mother, the
husband the father. During this stage also, the child starts going to school, which is his
first significant contact with people outside of the family. Conflict with practices in the
home and school regulations may occur during this stage.
4. The Family with Adolescents
A family with adolescents has generally reached a stage when the parents are
approaching a middle life stage and the grandparents are in the later stage. Hence, it is
not only teenagers but also their parents who are undergoing crisis (i.e. identity) at this
stage.
5. Launching Family
This stage begins when the first child leaves home and ends when the last child
leaves home. In the Philippines, this is prolonged because unmarried children usually
stay with parents. Launched children start their own family life cycle.
6. Family in Later Years
This begins with departure of last child and continues through retirement of one or
both of the couple and ends when both are dead.
18
THE STAGES OF THE FAMILY LIFE CYCLE
Emotional Second Order First Order Problems

Family Process Changes Changes or Encountered at
Life of in Family Status Tasks Involved Each Stage of the
Cycle Transition: Required to Cycle
Stage Key Proceed
Principle Developmentally
Between Accepting 1. Differentiation of 1. Extend social Medical:
Families parent the self in contact outside
Unattached offspring relation to the of home 1.Episodic problems
young separation family of origin. includes dating
adult clubs, and
recreation
2. Development of 2.Job employment 2.Sexually

intimate peer transmitted
relationship
3. Establishment of 3. Living 3.Unwanted

self in work accommodatio pregnancy
n
4. Pre-employment
check up
Emotional:
1. Psychosomatic
problems
secondary to
new job, role
and peer group
2. Depression
secondary to
adjustment to life
away from
home, difficulty
in finding
employment
suitable life
partner parental
expectation
Social :
1. Peer group
pressure on
acquiring vices,
such as
alcoholism,
smoking
2. Fiancee
pressure for
marriage and
premarital sex
19
Family Life Emotional Second Order First Order Problems
Cycle Process Changes Changes or Encountered at
Stage of Transition: in Family Status Tasks Involved Each Stage of the
Key Required to Cycle
Principle Proceed
Developmentally
Newly Commitment 1. Formation of 1. Establishing a Medical 1:
Married to the new marital system home base in
couple system a place to call 1. Episodic
2. Realignment of their own problems
relationship with
extended 2. Establishing a
families and mutually 2. early pregnancy
friends to satisfying
include spouse system for 3. STD
getting and
spending 4. Job-related
money physical
examination
3. Establishing 5. Gynecologic
mutually problem
acceptable
patterns of 6. Infertility
who does
what and who
is accountable
to whom
Emotional & Social
4. Establishing a 1. Depression due
continuity of to forced early
mutually marriage and
satisfying unwanted
sexual pregnancy
relationship
5. Establishing 2. Jealousy to job,
system of friends, and
intellectual previous
and emotional fiancee
communication
6. Establishing a 3. Emotional
workable problems
relationship relating to new
with relatives role as a spouse
(communication,
7. Establishing personalities and
ways of character
interacting with differences in
friends and habits and
associates in background)
the community
4. Problems
8. Facing the relating to in-
possibility of laws, friends,
children and peers and
planning for money
their coming
5. Demands of new
role
6. Problems of
adjustment to
office and work
20
Family Second First Order Problems Problems
Life Order Changes or Tasks Encountered at Encountered at
Cycle Changes Involved Each Stage of the Each Stage of the
Stage in Family Cycle Cycle
Status
Required to
Proceed
Developmentally
Family With 1. Accepting 1. Supplying PARENTS: CHILDREN:

Young marital adequate space, Medical: Medical:
Children system to facilities and 1. episodic 1. Episodic medical
make equipment for medical problems
space for the expanding problems 2. accidents
children family. 2. OB-Gyne 3. GOBI
problems 4. Mental
2. Taking on 2. Meeting 3. family planning retardation
parenting predictable and 4. annual PE in 5. Poisoning
role unexpected the job
costs of family 5. STD Emotional & Social:
3. Realign- life with small 1. learning
ment of children. Emotional & deficiencies
relationshi Social: 2. child abuse and
p with 3. Sharing 1. peer pressure neglect
extended responsibilities on alcoholism
family to within the and other vices
include extended family including drug
parenting and between abuse and
and grand- members of the extra-marital
parenting growing family. affairs
roles 2. sexual
4. Maintaining inadequacies
mutually 3. spouse abuse
satisfactory 4. job-related
sexual problems
relationship and 5. problems on
planning for the child rearing
future children. 6. communication
problems
5. Creating and 7. in-laws
maintaining problems
effective 8. taking care of
communication the sick and
system in the old parents or
family. in-laws
9. financial
6. Cultivating the difficulties
full potentials of
relationship with GRANDPARENTS
relatives within Medical:
the extended 1. episodic
family. medical
problems
7. Tapping 2. degenerative
resources, diseases
serving needs 3. chronic
and enjoying debilitating
contracts outside diseases
the family. Emotional &
Social;
8. Facing dilemmas 1. psychosomatic
and reworking problems
philosophies. related to
illness and
loneliness
financial difficulties
21
Family Emotional Second Order First Order Problems
Life Process Changes Changes or Encountered at
Cycle of Transition: in Family Status Tasks Involved Each Stage of the
Stage Key Required to Cycle
Principle Proceed
Developmentally
The Family Increasing 1. Shifting of 1. Providing ADOLESCENT:

With flexibility of parent-child facilities for Medical:
Adolescent boundaries to relationships to widely different 1. drug and other
include permit the needs. substance abuse
children adolescent to disorders
independence move in and out 2. Working out 2. STD
of the system. money matters 3. acne, bad odor
in the family 4. gynecologic
2. Refocus on mid- with teenagers problems
life, marital and . 5. menstrual
career issues. 3. Sharing the problems
tasks of 6. allergies and
3. Beginning shift responsibilities other skin
towards concern of family living. diseases
for the older 7. circumcision
generation. 4. Putting the
marriage Emotional & Social;
relationship 1. sexual
into focus. experimentation
leading to
5. Keeping the teenage
communication pregnancy
s system open. 2. homosexuality
6. Maintaining 3. conflict with
contacts with parents
the extended 4. juvenile
family. delinquency
5. depression
7. Growing into secondary to
the world as a peer pressure,
family and as a identity crisis
person. and secondary
sex
8. Reworking and characteristics
maintaining a 6. child prostitution
philosophy of 7. suicidal
life. tendencies
PARENTS:
Medical:
1. common medical
problems
2. OB-Gyne
problems
3. pre-menopausal
symptoms
4. alcoholism and
other vices
Emotional & Social:
1. Middle life crisis
2. male climacteric
3. extra-marital
affairs
4. insecurities
secondary to
changing
appearance
22
Principle Proceed
Developmentally
Launching Accepting a 1. Renegotiating of 1. Adjusting to PARENTS:

Family multitude of marital system the physiologic Medical:
entries and as a dyad changes of 1. episodic medical
exits into the middle age. problems
family system. 2. Development of 2. Discovering 2. OB-Gyne
adult to adult new 3. Degenerative
relationship satisfaction in diseases
between grown- relation with
up children and spouse. Emotional & Social:
their parents. 3. Setting up a Depression due to:
comfortable a. career
3. Realignment of home for stagnation
relationship to themselves b. emptiness
include in-laws that syndrome
and accommodate c. over-dependent
grandchildren. periodically married children
4. Dealing with other members d. early retirement,
disabilities and of the family. financial
death of parents, 4. Helping their problems
grandparents. adolescent e. extra-marital
children to free affairs
themselves f. taking care of
and become the sick parent
responsible or in-law
and happy g. Adjustment of
adults with new member of
families of their the family
own. through
5. Re-examining marriage.
their living
arrangement CHILDREN:
with their own Medical;
parents. 1. episodic medical
6. Adjusting to problem
the reality of 2. OB-Gyne
their own work 3. Medical
situation. problems of
7. Assuring adolescence
security for
their later Emotional & Social:
years. 1. independence
8. Participating in and dependency
community life. problem
9. Reaffirming the 2. juvenile
values of life delinquency
that have real 3. peer group
meaning esp. pressure on
dependent vices
newly married 4. problems of old
children. relatives
10. Sexual 5. conflict with
relationship parents
with spouse. 6. problems on
adjustment to
married life
23
Principle Proceed
Developmentally
The Accepting the 1. Maintaining own 1. Adjusting to PARENTS &

Family In shifting of and or couple physiologic GRANDPARENTS:
Later Life generational functioning and changes of Medical:
goals interest in the later life. 1. degenerative
face of diseases
physiologic 2. Re-examining 2. episodic medical
decline, their living problems
exploration of arrangements. 3. gynecologic
new familial and problems
social options. 3. Participating 4. urologic
in-group problems
2. Support for more activities.
central role for Emotional & Social:
middle 4. Maintaining 1. Depression due
generation. contact with to death of
younger spouse and
3. Making room in generations. sickness
the system for 2. psychosomatic
the wisdom and problems
experience of secondary to
the elderly children leaving
generation the home
without over- 3. loneliness
functioning 4. financial
them. adjustment
4. Dealing with loss CHILDREN:

of spouse, Medical:
siblings and 1. episodic medical
other peers and problem
preparation for 2. OB-Gyne
own death, life problems
review and 3. Menopausal
integration. problems
24
___________________________________________________
THE
PHILIPPINE ACADEMY OF FAMILY
PHYSICIANS, INC.
___________________________________________________
IMPACT OF ILLNESS
ON
THE FAMILY
25
IMPACT OF ILLNESS
ZORAYDA E. LEOPANDO, MD
Training in Medical School should focus on treatment of disease

problems and management of illness problems. Medical care should result in
treatment of disease, which is technologically brilliant as well as adequate
treatment of illness. Ancient form of healing focused on the experience of the
patient & his family, providing them with meaning & hope, relieving the sufferer's
sense of despair, impatience & isolation should be revived.
WHY STUDY IMPACT OF ILLNESS?

1. Sickness of patient causes suffering & severe disruption for the patient's
family (way of life & ability to function). Thus, when a patient is sick, the
whole family suffers.
2. Particular illness sets in motion processes that are disruptive of family life &
hazardous to the health of family members. Thus, there is role reversal,
income loss, and disruption of activities & danger of transmission.
3. Patient's disease is embedded in a whole matrix of difficult family problems
that contribute to the disease process itself:
- Poverty
- Unemployment
- Other sickness in the family
- Chronic family dispute
- Poor nutritional habit
- Inadequate housing condition
- Part of structured inequality in society that he cannot change
4. The interaction that takes place between the health care system and the
patient & his family are dependent on:
a. setting of care
b. type of cure
c. ability to pay
d. Flexibility/responsiveness of the health care system.
5. Impact of illness minimized by personalized care that is highly responsive &

flexible to the patient and the family members.
6. Illness, which is prolonged and complicated, results in structural change

within family system to the point that leads to different roles and functions.
STUDIES HAVE SHOWN THAT:

a. there are psychological & social effects on the family of a patient
with chronic or life threatening illness;
b. there are effects on parents & sibling of the illness of a child;
c. Severe illness in parents place children of family at greater risk.
DISEASE VS. ILLNESS
The two represent one phenomenon but 2 aspects of sickness.
Disease: Illness:
- primary biologic & psycho- includes the sufferer's
Physiologic disorder. experience of the disease & the
broad range of dislocations felt
by both the sufferer and his
family
Deeply embedded in the social,
cultural & family context of the
person who is ill.
26
DISCOVERING THE MEANING OF ILLNESS FOR THE FAMILY
Investigate disease: Investigate illness:

Examining clinical and exploring the meaning of illness
laboratory evidences of biologic to the patient and the patient's
and psycho-physiologic family
dysfunction.
HOW IS INVESTIGATION DONE?

THE PHYSICIAN:
Explores the patient's explanatory models because the belief held by a
person explains the nature of illness.
explore for patient's understanding of the following issues:
etiology of his illness
its pathophysiology
trajectory & outcome of his illness
appropriate treatment
.
Explores the patient's perception, reaction to symptom, how & why he seeks
medical advise & care, follow-up regimen & care for himself. This should be
the basis for communication.
Consider that the popular concept of illness is by individual, family, ethnic

group, social class and society. The belief drawn from scientific medicine,
religious beliefs, ancient healing sciences, popular account & healing groups
also affect the belief model.
investigate the broader set of experiences and concerns that patients

associate with their illness
derived from past experience with therapy
personal meaning associated with disease & forms of therapy &
self-consciousness about tacit meanings of certain diseases &
disabilities
Meaning of illness for other members of the family & their vulnerability.
THE FAMILY ILLNESS TRAJECTORY - PASSAGE THRU

SUFFERINGS
normal course of the psychosocial aspects of disease for the patient and
the family
knowledge of trajectory allows the physician to predict, anticipate & deal
with a family's response to illness
Indicates normal & pathologic responses thus enabling family physicians to
formulate special therapeutic plan.
MAJOR ILLNESSES INVOLVING LOSS OF:
1. Body parts
2. Ability to carry outs normal & treasured activities
3. Sense of self - esteem
4. Dreams & plans for the future
5. sense of invulnerability of one's self & in love ones that keeps existential
fears of impending death & separation at bay
THE STAGE IN FAMILY ILLNESS TRAJECTORY ARE:

STAGE I Onset of Illness to Diagnosis
STAGE II Impact Phase - Reaction to Diagnosis
STAGE III Major Therapeutic Efforts
STAGE IV Recovery Phase - Early Adjustment to Outcome
STAGE V Adjustment to the Permanency of the outcome.
27
Stage I - ONSET OF ILLNESS
The warning sign of malaise which initiates preliminary stage of the illness
trajectory.
The stage experienced prior to contact with medical care providers. Medical
beliefs & previous experiences provide influence to meaning of illness.
Nature of onset may play an important role on impact of illness on a family &
some meaning of experiences are formulated here.
Nature of Nature of Onset Characteristics Impact

illness of on
Experience Family
Acute, rapid rapid, provide little time caught up in
illness/accident clear for physical and suddenness
onset psychological deal with
adjustment; immediate
decision
short period often with little
between onset, support from
diagnosis and within and
management outside the family
thereby leaving unit
little time to if less
remain in state of threatening, may
uncertainty be dramatic but
less crisis
oriented problem
for the family
Chronic, gradual suffer from state vague
especially onset of uncertainty apprehension
debilitating over meaning and anxiety
and symptom fearful fantasies
over denial of
seriousness of
symptoms and
possible
implications
RESPONSIBILITIES OF THE PHYSICIAN
1. explore routinely the explanatory model & fear that patients bring to the
Clinic set-up.
2. with inappropriate label of illness, acknowledge & explore conflict the
patient maybe experiencing
3. explore several aspects of pre-diagnostic phase of patients & families
STAGE II - REACTION TO DIAGNOSIS: IMPACT PHASE

1) The physician who presents the diagnosis is responsible for making a clinical
judgment about the amount of information the patient can absorb, given his
present level of anxiety or shock. It is important that the physician elicits
explanatory model of diagnosis to patient if disease is not life threatening and
patient is liable to be unduly alarmed.
2) Disease and appropriate treatment can be described according to the
patients level of comprehension and understanding. Unnecessary frightening
anxiety may occur if informations are not understood.
3) Give small doses of informations over time if the diagnosis is particularly
traumatic and the patient and his family may be unable to receive so much.
4) If diagnosis is confusing and stressful and shuttering, the family physician
must:
provide support, and continuity of care
interpret findings which are misunderstood
offer advise and encouragement
and clarify meaning of specialist's message & outcome of illness and
operation
28
2 PLANES OR AREAS BY WHICH FAMILY & PATIENT REACT AND
ADJUST:
EMOTIONAL PLANE COGNITIVE PLANE
During onset of illness, initially

there is denial, disbelief and PHASE 1: Initially there is
anxiety. tension & confusion with
protest diffuse directly over probable lack of capacity for
unfairness (minutes to problem solving
hours) threat sets in motion tension
reduction mechanism
this is followed by emotional
upheaval characterized by PHASE II: repeated failure in
strong emotions such as anger, deriving the diagnosis may lead
anxiety and depression to exacerbation of tension &
depends on disrupted roles increase distress
and channels (period of resort to prayers
weeks) still earn capacity to problem
solve
The last phase is
accommodation during which
the patient and the family learn PHASE III: increasing
to accommodate and accept the assessment and receptivity of
diagnosis. family to new approach for relief
This is very important for the of distress
implementation of some go doctor shopping
therapeutic plans. some are willing and capable
for active participation
time for real opportunity for
the physician and other
health workers to assist
family in realigning roles and
expectations, learn new skills
and make adjustment
willing to accept
responsibility
PHASE IV: eventual acceptance
of diagnosis will enable them to
mobilize resources & recognize
the family.
quality of family
reorganization
if there is no movement
towards this phase, family
will be inefficient in achieving
healthy adaptation to the
crisis and reorganize at more
dysfunctional level
RESPONSIBILITIES OF THE PHYSICIAN?

1. Anticipate number of problems and help families to cope and adapt
more through family conference, discussion with parents, etc.
2. Specifically,
The family should from the very beginning be encouraged to make
clear to each other & to the patient the nature of the illness by helping
family maintain openness that allows sharing & support. Pattern of
non-sharing / silence limit the openness & spontaneity of families and
hampers their ability to share & openly support each other. Process of
isolation is more terrifying and may be perceived as abandonment by
the patient.
The physician should know that feeling of guilt is a natural response to
stress of grief and loss.
Family members may have the irrational feeling that they personally
caused the patient's disease.
The physician should help family members anticipate such feelings &
make realistic efforts to relieve patient of self- blame through careful
explanation of etiology.
29
3. The physician should help the family assess the likely effect of the
illness on the family, predict problems likely to arise; develop plans for
realistically coping with them; and assess the family capabilities to deal
with such stress.
4. The physician should briefly help the family understand some of the
problems as well as benefits to be expected from family & friends who
offer support.
5. Offer alternative interpretation of proposed therapeutics-bolster family's
denial & inability to accept reality.
STAGE III. MAJOR THERAPEUTIC EFFORTS

management / therapy represents one of the most challenging & rewarding
part of medical practice
The physician should deal with multiple variables, works in harmony of the
wishes of the patient and family, and coordinates all aspects of the therapy,
which involve specialist & others.
CRITICAL ISSUES IN CHOOSING THERAPEUTIC PLAN

1. Psychological state and preparedness of the patient and family
determine the choice of therapeutic plans as well as the
alternative choices.
If the patient's belief system & trust in therapeutic modality is at
variance with that of physician, he may resist attempt at education and
reassurance. Thus, the physician should investigate for signs of
non-compliance.
Some of patients' families are not emotionally equipped to undertake
some form of therapy so other professional help should be obtained.
2. Assumption of responsibility for care very early in the treatment
plan. Thus, we have to establish & define responsibilities of each
party. Give realistic role to everyone.
3. Economy of Therapeutic plan -> Of what good is therapy if family
cannot afford it. The sickness will have devastating effects on the
family economically speaking.
Diligence on the part of physician in keeping costs down by involving
family in all major decisions which affect the patient as in-request for
tests/referrals which are really necessary.
Economic Impact of Illness
a. emotional trauma
b. social dislocation
c. economic catastrophe - wipes out family savings
4. Life style & cultural characteristics of a family are important in
choosing a therapeutic plan.
5. Effects of hospitalization, surgery and other major therapeutic method
are emotionally stressful for the patient's family. There is fear &
concern in the families who are still essentially helpless, unable to
participate in the suffering or need to relieve the constant discomfort or
anguish.
Hospitalization gives rise to stressful logistic problem
a. Father - special economic burden
b. Mother - greatest impact on other family members. It poses
High risk of family dysfunction.
c. Children - special syndrome of emotional problems of families.
- Hostility, abandonment
d. Parents - helpless, guilt, frustrated, or hurt
e. Geriatric - vulnerable to fears of death, rejection,
abandonment,
Loneliness & helplessness
Hospitalization
^ Loss of member - reserve position upon return
^ Conflict between family and hospital staff - intrusion
RESPONSIBILITIES OF THE PHYSICIAN
1. Remain open to the family, indicate they will not be abandoned, provide
them information.
2. Deal with multiple variables; consider all factors in planning.
3. Work in harmony with patient & family.
4. Coordinate all aspects of therapy.
5. Anticipate pathologic response. Such responses of family members occur
when there is severe emotional symptom of deep depression;
psychological reaction and organic symptoms behavioral problem like
addiction to alcohol work inhibition and pathologic acting out.
30
STAGE IV - EARLY ADJUSTMENT TO OUTCOMES - RECOVERY
Return from the hospital or major therapy initiates a period of gradual
movement from the role of being sick to some form of recovery or adaptation,
with corresponding adjustments of relation within the family.
Experience of recovery or adjustment to the illness outcome is an important
phase for patients & families. It varies according to the type of outcome
anticipated.
Simplest outcome is return to full health
* Gains from illness experience
* Patient nurtured & allowed to take over the abandoned obligation,
New responsibilities and privileges when sick.
Partial recovery followed by a period of waiting to learn if disease will
return or fear of death, because of long period of waiting. They
maintain constant sense of vulnerability.
Recovery is quite different if it requires acceptance of a known
permanent disability.
RESPONSIBILITIES OF THE PHYSICIAN:

1. Deal with immediate effects of trauma.
2. Alleviate anxiety & assure adequate rest.
3. Psychological support can be given through understanding and
repeated reassurance.
4. Explore level of understanding of patient & family. Call on other
members of family for means of support. Try to find out how members
understand what happened, what kind of labeling do they have. Do
they label person as still ill or do they label him as once again well or
has returned to health.
STAGE V. ADJUSTMENT TO THE PERMANENCY OF THE

OUTCOME
This points to the family's adjustment to crisis.
The second crisis occurs as family realizes that they must accept & adjust to
a permanent disability. The whole family must begin & give up hope for the
patient's full return to health. They have to accept that life must go forward &
pattern believed to be temporary must be accepted as permanent. The family
physician should be aware that continued unwillingness to incorporate that
reality of the permanency of the loss may be a sign of pathology.
Coping mechanism is developed during earlier stage of family adjustment.

Person who is sick continued to be treated as sick & he is treated as
patient & not reintegrated into the family
Treat patient as recovered, full, responsible person
For Acute Illness: There is potential for crisis especially when family routines
are suspended. Emotions are high & can lead to anger especially if the
family perceives that the care given by the doctor is not satisfactory. Because
of suddenness of illness, family may find it difficult to face the stress.
What the family physician can do is to facilitate healthy response or

Acceptance of diagnosis & recognize danger signals such as delayed or
Prolonged reaction.
For Chronic Illness: Because of prolonged fear & anxiety, there is higher
incidence of illness in other members of the family. If the chronic illness
brings about additional burden & sometimes feeling of guilt especially if the
sick member was previously neglected, then as a result of this feeling, the
family becomes over-indulgent toward the sick member & this will later result
into feeling of overwork. Thus, anger & resentment toward sick member sets
in leading back to feeling of guilt later.
What the physician can do is to encourage ventilation of feelings, give

reassurance and reinforcement for care.
For Terminal Illness: This is highly emotional & potentially devastating. The
moment of diagnosis of a major debilitating or terminal disease is often
remembered by patient in their families as the single most difficult time of the
entire illness experience. As a reaction to shattering diagnosis, the patient &
his family anticipate grief reaction. If the family is functional, members will be
31
drawn close together to provide care & support to the patient & to each other.
If the family is dysfunctional, it can be the seed for future family discord and
breakdown.
The initial response in diagnosis of terminal illness is that of shock &
overwhelming anxiety. As they respond to the pain with denial and
disbelief, the patient may say, "this could not be happening to me."
The Physician can:
(1) Assist the patient and the family in relating to health care system;
(2) Aid the patient & the family in efficient & functional readjustment;
(3) Provide quality care. Home care is the best & most accepted & the
last demanding, thus it should be facilitated.
Family Reaction to Death

- In after prolonged severe illness and adaptation and reaction are
Already accomplished
- Death comes swiftly & MD to assist family to cope.
- Stage of Denial - few days to few weeks
- If prolonged - premorbid pattern of abnormal behavior
Anger Depression
Bargaining Acceptance
FAMILY IN CRISIS
Family is in crisis when it moves into a state of dis-equilibrium in response
to any situation or event that it cannot resolve by use of available
problem-solving skills, behavior or resource. When illness is perceived as threat
to its equilibrium, a crisis response is set in motion.
EVALUATING FAMILY IN CRISIS

1. Assess Family History of coping with problem & stressor.
Boiling point at which crisis response is set in motion
affected by uniqueness of internal & external
factors
stresses are sufficient in number or intensity to
disturb family equilibrium
Family psychosocial history provides information
regarding capacity of family to cope with illness &
other missions.
Quality of Family Life -> mobilize their own
strengths and resources to cope adequately with
stress.
2. Determine style of Family Development
Anticipatory Guidance
timeliness of illness or problem -> affects family's
ability to cope
3. Role of Patient in the Family-
member providing financial support -> financial
problem
Member plays critical role in family emotional life,
i.e. mom who nurtures, emotional support -> most
serious impact in family when she gets sick.
Impact: feelings of guilt & self blame
child -> other siblings deprived, develop
resentment towards the ill sibling
4. Monitoring Role Disruption
assesses and monitors effect of role disruption
Identifies gap in family role that exists or the
results of the illness and helps the family explore
options for filling those gaps from within & outside
of the family.
Sick Role as perceived by patient & family.
32
___________________________________________________
THE
INC.
___________________________________________________
TOOLS
IN
FAMILY ASSESSMENT
33
TOOLS FOR FAMILY ASSESSMENT
ALEJANDRO V. PINEDA, JR.,MD
The patient is a member of a family and studies have shown that the way a patient
reacts to an illness depends a lot on his family. Many health problems seen in practice
can neither be understood nor successfully dealt with when considered as isolated
phenomena affecting only one person. The works of several investigators lend
credence to the hypothesis that the treatment of the family as a unit yields more certain
and complete diagnosis, better medical outcome, and better benefits with regard to
prevention. Thus, it depends entirely on the family physician to what level he will
involve the family in evaluating a patient's problem. This discussion presents an
overview of family systems medicine and outlines the way in which a practicing family
physician can incorporate family orientation into clinical practice.
Overview of Family Systems Medicine

A patient who comes to the clinic with a health problem cannot be fully understood
by considering only the patho-physiology of the medical problem. Better evaluation and
thus, better health care results if family relationships, family social and cultural systems
are all considered. The family physician in practice views the patient's problem in
multiple context. Herein lies the focal point of Family Systems Medicine. A family
systems approach to common clinical situation can facilitate a new level of
understanding of a patient's problem. However, to be able to develop a family systems
approach to patient care will require the understanding of some basic concepts about
the structure and function of the family.
INCORPORATING A FAMILY SYSTEMS APPROACH INTO CLINICAL

PRACTICE.
STEP ONE: RECOGNIZE FAMILY STRUCTURE

The very first step in understanding the family is to know the individuals in the family.
The following information should be obtained: names of the individual family members;
place of residence; specific roles in the family; stage of the family in the family life cycle;
and significant dates in the family (marriage, birth, death, etc.).
A good way to obtain and record this information about the family structure is to
complete a Family Genogram. The Family Genogram is a scheme or graphic chart
representation of both the genetic pedigree of family and key psychosocial and
interactional data using standardized symbols.
The Family Genogram.

This is a graphic representation of the following components of a family.
A. Family Tree, its description:
1. It must consist of 3 or more generations and each generation is identified by

Roman numerals.
2. The first-born of each generation is farthest to the left, with siblings following to
the right in order of birth.
3. The family name is placed above each major family unit.
4. Given names and ages are placed below each symbol.
5. One member of the family is of greater medical significance because of an illness
and he is known as the index patient and is identified with an arrow.
6. Date is indicated when the chart was developed so that ages would be adjusted
over time.
B. Functional Chart
This gives a more dynamic image of the family, especially of relationship of
members. It allows one to judge the totality of the family unit, its strengths (as in strong
bond between the husband and wife) and weaknesses (as in the presence of marital
discord or separation of the parents) and its ability to withstand future stressful
situations (as knowing those who are actually living together in the household).
C. Family Illness/History
This denotes the presence of inherited diseases or familial tendencies indicating
potential problems in the family.
34
Step Two: Understanding Normal Family Function
The five basic functions performed by all families are:
1. Families provide support to each other. Support can be physical, financial,

social, and emotional. Families do a lot of things together as a unit and have a
sense of belonging to one another.
2. Families establish autonomy and independence for each person in the system,
which enhance personal growth of individuals within the family. Each
individual in the family has defined roles to play within and outside the limits of the
family. Thus, while families do a lot of things together, they do other things
separately. The essence of the autonomy function is the ability to maintain the
integrity of each individual member.
3. Families create rules that govern the conduct of the family and of the
individuals within the family. These rules often deal with interaction patterns,
privacy, authority, and decision-making. These are rules of behaviors that are
mostly unwritten and become apparent when an outsider visits the family.
4. Families adapt to change in the environment. It is essential that the family

adapts changes and grows in order to progress from one stage to another in the
family's life cycle. There are two types of changes. The first order change involves
adaptation to environment change that requires minimal change in the family
structure. An example is a change that is present when a family moves to a new
locality. The second order change involves fundamental change in the family
structure. A good example is when a family moves into the stage of the birth of the
first child.
5. Families communicate with each other. These are mostly verbal, non-verbal, and
implied messages. Other functions become impossible without communication.
It is now easier to define a functional family. A balance should be established

between these functions. Imbalances result from over-emphasis or under-emphasis on
these functions. Communication is very important in coping with changes and stresses.
The family function breaks down when the family's ability to cope is overwhelmed and
the needs of family members are chronically unmet.
Thus, a dysfunctional family is defined as a family with chronic inability to

respond to the needs of the members or to cope with changes and stresses in the
environment.
FIRM RULES
Normal Families
RIGID
STRUCTURED
AUTONOMY DISENGAGED SEPARATED CONNECTED SUPPORT

& &
INDIVIDUATION ENMESHED FAMILY
CLOSENESS
FLEXIBLE
CHAOTIC
ADAPTABILITY
MODIFIED TWO-DIMENSIONAL MODEL OF FAMILY FUNCTION

Normal families tend to fall within the shaded circle.
35
Before progressing to a pragmatic format for family study, a model is needed to
present an empirical view of the response that may result when family members
experience stressful life event. This is designed to reflect the pathways that must be
explained in assessing these responses.
Family in
Functional Stressful
Equilibrium (1) life event (2)
(Functional or nurturing)
Adaptation
[Coping] (5)
Resources
Adequate (4)
Family in
Disequilibrium (3)
Resources Inadequate (6)
Crisis (7) Extra-Familial

resources (8)
Maladaptation
Pathologic Defense
Mechanism (9)
Terminal Pathologic Stressful Life

Disequilibrium (12 Disequilibrium (10) Event (1)
SMILKSTEINS CYCLE OF FAMILY FUNCTION

The cycle of Family Function: A model for family response to stressful life event.
A stressful life event, which occurs in a family in functional equilibrium, puts the
family in Disequilibrium. If the resources are adequate adaptation or coping are utilized
to bring back the family into a functional equilibrium.
However, if the resources are inadequate, crisis ensues. But, if the extra-familial
resources are adequate, adaptation will occur to bring back the family into a functional
state. If still extra-familial resources are inadequate, some forms of maladaptations of
the family members are seen. Here, pathologic defense mechanisms such as denial,
repression, somatization and projection are employed.
A maladapted family either goes to terminal dis-equilibrium in which the family

disintegrates or to pathologic equilibrium in which interaction is impaired due to some
unresolved crisis. Members utilize abnormal defense mechanisms such as depression,
isolation, delinquency, school failure or running away from home.
CHECKLIST TO ASSESS FAMILY FUNCTION
1. How many are there in the family?

2. Who lives at home?
3. In what phase of Family Life Cycle is the family?
4. What problems do this phase raise for them?
5. What major problems has the family had in the past?
6. Does the family feel these problems were dealt with satisfactorily?
7. Is there any history of alcoholism, drug abuse or dependency?
8. How are major decisions made in the family & by whom?
9. Are the in-laws & relatives helpful?
Do they create problems for the family?
10. Do the family members have many friends in the neighborhood?
To what groups or clubs do family members belong?
11. What community resources has the family used?
Would the members use them again?
36
12. Has this family not used community resources at times when they would have been
appropriate?
13. a. what does each parent expect of each child, both on day to
day basis & for the future?
b. What do the children expect of each parent?
c. Are these expectations realistic?
14. What does each member of the family have to do to get attention?
15. How much tolerance for individual differences is there in the family?
16. What are the goals, interests, and values of the family?
17. Do all the family members work together toward these goals?
18. What is the educational level & financial status of the parents?
STEP THREE: LEARN TO ASSESS FAMILY STRUCTURE AND FUNCTION IN

CLINICAL PRACTICE.
Meeting the family as a unit has become the standard medical practice in the
context of a patient with life-threatening ailment who is brought to the emergency room,
chronic illnesses or even death of a family member. However, the process involves
transfer of clinical information from the doctor to the family members.
To assess the family, the flow of information should be otherwise. The family
physician should be able to listen more and talk less. More often than not, family
physicians are unprepared to convene families for family assessment. Thus, family
assessment tools have been devised to aid the family physician in practice. Each of the
family assessment tools has its own advantages and disadvantages. A common
waterloo of a lot of these instruments is that they obtain data from only one family
member. But this does not deter the family physician to use such tools often.
Family Assessment Instruments.
1. Family Genogram
2. Family Circle
3. Family APGAR by Smilkstein
4. FACES (Family Adaptability and Cohesion Evaluation Scale)
5. FES by Moos (Family Environmental Scale)
6. Clinical Biography & Life Events
7. SCREEM
8. DRAFT (Draw A Family Test)
FAMILY GENOGRAM.
Uses/Informations:
1. records names and roles of each member of the family.
2. separates extended family into several household
3. documents medical problems of each member of the family.
4. documents significant dates in the family history.
5. reveals more subtle information about the family.
The Genogram is a very excellent tool to use in learning about the family
structure. However, it has limited role in assessing family functions. To complete a
basic family Genogram, 10-15 minutes are needed making it impractical in routine clinic
visits. It has been suggested to place the basic structure of the Genogram in the chart
to shorten time consumption.
THE FAMILY CIRCLE.
Thrower has described this family assessment technique, ET al. Family circles are
often used on individuals, but they can be applied to small groups as well. The family
physician draws a large circle on a piece of paper and instructs the patient as follows:
As a family physician, I am interested in you, your family, and what is important to

you. Let this circle stand for your family as it is now. Draw in some smaller circles to
represent yourself and all the people important to you --family and others. Remember,
people can be inside or outside, touching or far apart. They can be large or small
depending on their significance or influence. If there are other people important enough
in your life to be in your circle, put them in. Initial each circle for identification. There
are no right or wrong circles.
37
The advantage of this particular tool is the fact that the family physician can see
another patient during the time the other patient is busy completing the Family Circle
technique. Actual assessment of the family occurs when the patient explains the
diagram he or she made. A disadvantage of this tool is the difficulty one encounters in
standardizing and interpreting this particular assessment instrument.
DRAW A CIRCLE TEST:
FAMILY APGAR.
This assessment tool was originally described by Smilkstein and consists of 5

questions to assess family function. The Family APGAR is a rapid screening instrument
for family dysfunction. It has adequate reliability and validity to measure the individual's
level of satisfaction about family relationships. This particular assessment tool requires
the family physician little time to complete. Also, it helps the family physician to decide
which families need more careful assessment.
APGAR stands for acronyms of:
1. Adaptation is the capability of the family to utilize and share inherent resources,
which are either Intra-familial or extra-familial.
2. Partnership is the sharing of decision-making. This measures the satisfaction

attained in solving problems by communicating.
3. Growth refers to both physical and emotional growth. This measures the
satisfaction of the available freedom to change.
4. Affection is how, emotions like love, anger, and hatred are shared between
members. This measures the members' satisfaction with the intimacy and
emotional interaction that exist in the family.
5. Resolve refers to how time, space, money are shared. This measures the
members' satisfaction with the commitment made by other members of the
family.
4 basic situations where the Family APGAR is needed:
1. When the family will be directly involved in caring for the patient.
e.g. Post MI/CVA patients with specific disabilities that will require rehabilitation
therapy.
2. When treating a new patient in order to get information to serve as general view of
family function. All Family Health Care Programs shall have the initial APGAR
scoring of families enrolled in their clinic.
3. When treating a patient whose family is in crisis e.g. family therapy for drug
addicts.
4. When a patient's behavior makes you suspect a psychosocial problem possibly

due to family dysfunction. Generally, patients who have high clinic utilization
(greater than 9 visits per year) have significantly lower APGAR SCORES (more
dysfunctional family)
38
FAMILY APGAR QUESTIONNAIRE
PART I
Almost Some of Hardly
Always the Time Ever
A I am satisfied that I can turn my

family for help when something is
troubling me
P I am satisfied with the way my family

talks on things with me & shares
problems with me
G I am satisfied that my family accepts

& supports my wishes to take on new
activities or directions
A I am satisfied with the way my family

expresses affection and responds to
my emotion such as anger, sorrow,
and love
R I am satisfied with the way my family

and I share time together
TOTAL
PART I: Helps define degree of patient's satisfaction or dissatisfaction with family
function.
FAMILY APGAR II
Questionnaire:
Who lives in your home? How you get along?
Relationship Age Sex Well Fairly Poor
If you don't live with your own family, How you get along?
list the persons to whom you turn to
for help
Relationship Age Sex Well Fairly Poor
Part II delineates relationship with other members. Also, it identifies persons who
can give assistance to the patient. And lastly, it indicates conflict not revealed in Part I.
The scoring:
almost always = 2 points
some of the time = 1 point,
hardly ever = 0 point.
Then add up the points.
A total of 8-10 points = highly functional family

4- 7 points = moderately dysfunctional family
0- 3 points = severely dysfunctional family
39
FILIPINO FAMILY APGAR QUESTIONNAIRE
L. Cabahug, MD and A. Pineda, Jr., MD in there published research entitled

Family APGAR: Its Validation Among Filipino Families Emergency Room, Out Patient
Department Sto. Tomas University Hospital, January to April, 1992 showed that the
translated Filipino APGAR approximated the English version in content, signifying
reliability index. Variables like sex, marital status, educational attainment and monthly
family income did not affect the APGAR scores between the two versions. Ease of
administration of the Filipino version depicted in the time when answering questions
would favor its acceptability by Filipino Family Medicine Practitioners.
PART I
SAGUTIN AND MGA SUMUSUNOD AYON SA RELASYON NINYONG MAG-ANAK.
PALAGI PAMINSA HALOS
N-MINSAN HINDI
(2) (1) (0)
A Akoy nasisiyahan dahil nakakaasa
ako ng tulong sa aking pamilya sa
oras ng problema.
P Akoy nasisiyahan sa paraang

nakikipagtalakayan sa akin ang aking
pamilya tungkol sa aking problema.
G Akoy nasisiyahan at ang aking

pamilya ay tinatanggap at
sinusuportahan and aking mga nais
na gawin patungo sa mga bagong
landas para sa aking ikauunlad.
A Akoy nasisiyahan sa paraang

ipinadadama ng aking pamilya ang
kanilang pagmamahal at
nauunawaan ang aking damdamin
katulad ng galit, lungkot at pag-ibig.
R Akoy nasisiyahan na ang aking

pamilya at ako ay nagkakaroon ng
panahon sa isat-isa.
PART II
Sino-sino ang nakatira SA inyong tahanan? Paano ang iyong relasyon?
PANGALAN RELASYON KASARIAN MABUTI HINDI HINDI
GAANONG MABUTI
MABUTI
1.
2.
3.
4.
Kung Hindi ka nakakahingi ng tulong SA Paano ang iyong relasyon?

iyong sariling pamilya, kani-kanino ka
humihingi ng tulong?
PANGALAN RELASYON KASARIAN MABUTI HINDI HINDI
GAANONG MABUTI
MABUTI
1.
2.
3.
4.
40
FACES (Family Adaptability and Cohesion Evaluation Scale)
The basis of this assessment tool in the Olson's circumflex model of Family Function.
Face is a self-reported scale wherein the patient rates his or her family on 30 items on a
1 to 5 scale.
FES (Family Environment Scale)
This tool is a 90-item questionnaire developed by Moos. Separate scales of Family

Parameters are included in the results. It is being used as a research tool to compare
health care results with family variables.
CLINICAL BIOGRAPHIES AND LIFE CHART
We know that illness is not randomly distributed within or among population. Some
people get sick more often than others. The individual's experiences with health and
sickness are connected with his personal life. If doctors understand the life story and
the connections between a person's experiences of health and illness, they might be
better doctors. Clinical biographies and life charts are valuable tools, which can
facilitate analysis of connection. If life events and clinical events are put side by side
according to dates of occurrence, we will be able to show the correlation between the
two.
SCREEM
Very important in the assessment of the family as to its capacity to participate in

provision of health care or to cope with crisis is the SCREEM method of Analysis.
SCREEM is an acronym that stands for Social, Cultural, Religious, Economic,
Educational & Medical factors affecting health. These factors can be considered as
resource and as pathology.
Resource Pathology
______________________________________________________________________
Social
Social interaction is evident among
family members. Family members have * isolated from extra-
well-balanced lines of communication familial
with extra-familial social groups * problem of over-
such as friends, sports, clubs, and commitment
other community groups.
Cultural
Cultural pride or satisfaction can
be identified, especially in * ethnic/cultural
distinct ethnic groups. Inferiority
Religious
Religion offers satisfying spiritual
experiences as well as contacts with * rigid dogma/rituals
an extra-familial support group.
Economic
Economic stability is sufficient to * economic deficiency
provide both reasonable satisfaction * inappropriate economic
with financial status and an ability plan
to meet economic demands of normative
life events.
Educational
Education of family members is
adequate to allow members to solve * handicapped to
or comprehend most of the problems comprehend
that arise within the format of the
life style established by the family
Medical
Medical: Health care is available
through channels that are easily * not utilizing health
established and have previously care facilities/
been experienced in a satisfactory resources
manner.
______________________________________________________________________
41
DRAW-A-FAMILY TEST: (D.R.A.F.T.) COMMUNITY-BASED FAMILY ASSESSMENT
TOOLS
R. Cruz MD and A. Pineda, Jr., MD designed a simple, practical and cost

effective tool for assessing family functions. DRAFT is a projective technique that can
be administered individually or in-group test. It does not only provide clues on individual
family members with regards to their personalities but also serve as a diagnostic device.
Here, members of the family (Father, Mother and Siblings) find opportunity for self-
expression consequently revealing and relieving innate difficulties within the family
system.
After interview, the family will be informed of the purpose of the assessment tool,
which was to gain more insights into family situations in order to have a better
understanding of the nature of their problems. The family can be seated around a table
where each family member can be provided with a blank, clean unruled bond paper and
a lead pencil with an eraser. Subjects are to be instructed as follows: Kindly draw your
family and its members, the whole body, you may include and exclude anybody you
wish. Theres no right or wrong, you can draw any member of your family who comes
first into your mind. Take your time, there are no hard and fast rules.
The examiner notes subjects comments, sequence in which the parts are drawn
and other procedural details. Drawings will be analyzed using the interpretations made
by a Clinical Psychologist based on Draw-A-person Test and Kinetic Family Drawing.
Projective drawing like DRAFT has been found to be useful and revealing
because of the following reasons:
1. Patients exhibiting evasiveness and guardedness seem more likely to reveal

their underlying traits and psychodynamics in the drawing because subjects
are more intellectually aware of what they might expose through verbal
communications.
2. Drawing can be an expression of the unconscious label that represents an
adultered basic needs.
3. Drawings are first to show incipient psychopathology and the last to loose
signs of illness after patient recovers.
The DRAFT does not however measure the persons inherent ability to draw but
how he pictures his family members. The configuration of the father, mother and
siblings, the sequence of succession, quality of lines and significant details like
omissions of some parts are all-important in the evaluation and interpretation.
Identifying the possible risk factors that are present in each member of the family using
this screening device is one of its advantages.
42
FAMILY ASSESSMENT MODEL [ San Jose State University (1982) ]
I. FAMILY IDENTIFICATION
A. COMPOSITION - who are the family members currently living in the household?
Are they kin or non-kin? What are their ages?
B. SOCIAL HISTORY - What is the social background of each member regarding

education, income, occupation, marital status, ethnicity, and cultural?
C. COMMUNITY & NEIGHBORHOOD - What is the general tone of the

neighborhood? Are resources such as water, electricity, and sewers available? Is the
area one of affluence or poverty? What are the residents of the neighborhood like (e.g.
friendly, non-committal)?
II. INDIVIDUAL AND FAMILY DATA

A. HEALTH HISTORY
B. FAMILY DYNAMICS - Dysfunction in the family dynamics is
often reflected in the health status of the family as a whole and of
individual members.
(1) TECHNIQUES - Include interviewing and observation
APGAR Score.
(2) RECORDING
> Communication patterns: direct or indirect, open or closed.
> Leadership: patriarchal, matriarchal, egalitarian, democratic.
> Hierarchies: Who possesses the power and over what areas?
> Roles and Relationships: Breadwinner, Decision-maker, leader, and
nurturer.
> Beliefs regarding health and illness: myths, wives' tales, and cultural
influences.
> Priorities: housing, job, food.
FAMILY MAPPING
A Family Assessment Tool developed by Salvador Minuchin, a Psychiatrist-

Family Therapist. This particular tool facilitates the communication of informations
about a family system to colleagues so that they can be understood.
A double line between two people indicates a functional

relationship.
____ / ____ A single line with a break in the middle indicates dysfunction.
Three parallel lines between two people denotes an over-involved

relationship where there is plenty of intrusion.
___|____ A solid line perpendicular to the relationship line symbolizes a rigid

boundary where the rules are clear but non-negotiable.
------- A broken line perpendicular to the relationship line symbolizes a

boundary that is clear but negotiable.
. . . . |. . . . . A dotted line perpendicular to the relationship line signifies a

boundary that is diffuse or unclear.
[ ] A bracket encompassing several people signifies the presence of a

coalition or alliance between these people.
An arrow pointing away from the system signifies escape from the
system.
An open ended arrow with its open end embracing two individuals
and the pointed end pointing to a third signifies that the third person
is being triangulated by the conflict between the other two.
43
REFERENCES
TEXTBOOKS
Essentials of Family Medicine / Philip D. Sloane, MD, Lisa M. Slatt, M.Ed. and
Richard M. Baker, MD; Williams & Wilkins - Baltimore Hongkong London Sydney, 1988.
Family Medicine: Principles And Practice, Fourth Edition / Robert B. Taylor MD,
editor: associate editors, Alan K. David MD, Thomas A. Johnson, Jr. MD, D.Melessa
Philipps MD and Joseph E. Sherger MD, MPH.; Springer-Verlag Heidelberg New York,
1994
Family Medicine: Principles And Practice, Third Edition / Robert B. Taylor MD,
editor: associate editors, John L. Buckingham MD, E.P. Donatelle MD, Thomas A.
Johnson, Jr. MD and Joseph E. Scherger MD; Springer-Verlag New York Berlin
Heidelberg London Paris Tokyo, 1988
Family Therapy and Family Medicine: Toward the Primary Care of Families /
William J. Doherty and Macaran A. Baird; The Guilford Press New York & London, 1983
Skills and Management in Family Medicine / E. K. Koh MD FRCGP FCGPS, L. G.

Goh, MD MBBS, M.Med(Int Med) FCGPS and patrick Kee, MD MBBS M.Med(Int Med)
FRACP; P.G. Publishing Singapore Hongkong New Delhi, 1988
Textbook of Family Practice, 4th Edition / Robert E. Rakel, MD; W.B. Saunders
Company-Philadelphia London Toronto Montreal Sydney Tokyo, 1990
PROCEEDINGS:
Making Medical Practice and Education More Relevant to Peoples Needs: The
Contribution of the Family Doctor, A Working Paper of the World Health Organization
and the World Organization of Family Doctors, From the Joint WHO_WONCA
Conference in Ontario, Canada November 6-8, 1994.
Making Medical Practice and Education More Relevant to Peoples Needs: The
Contribution of the Family Doctor, A 1998 Progress report on the 1995 World
Health Organization and the World Organization of Family Doctors Working Paper
DRAFT 3.
The PAFP Orientation Course in Family Medicine Proceedings / Zorayda E.

Leopando, MD, Nelson Rodriguez, MD, Isabelita M. Samaniego, MD, MPH, Alejandro
V. Pineda, Jr. MD and Rosalia Fabia-Bugayong, MD; Family Health and Guidance
Center Makati Philippines
The PAFP Strategic Planning Workshop: Program and Background Papers /

Sponsored by Wyeth Philippines, Inc. October 26-28, 1995 City of Springs, Los Banos
Laguna Philippines.
44
JOURNALS:
Liz Corazon Cabahug, MD and Alejandro V. Pineda, Jr., MD. Family APGAR: Its
Validation Among Filipino Families, Emergency Room, Outpatient Department,
Santo Tomas University Hospital, January to April, 1992. The Filipino Family
Physician, July-September, 1993; Volume 31 Number 3: 69-80.
Rafael B. Cruz, MD and Alejandro V. Pineda, Jr., MD. Draw-A-Family Test

(D.R.A.F.T.) Community-Based Family Assessment Tool. The Filipino Family
Physician, July-September, 1993; Volume 31 Number 3: 69-80.
Thomas L. Delbanco MD. Enriching the Doctor-Patient Relationship by Inviting the

Patients Perspective. Annals of Internal Medicine; 116:414-418, 1 March 1992.
Steven R. Hahn MD, Joel S. Feiner MD and Evan H. Bellin MD; the Doctor-Patient-
Family Relationship: A Compensatory Alliance. Annals of Internal Medicine, 1
December 1988; 109:884-889.
Alejandro V. Pineda, Jr., MD. Family Medicine - Attitudes and Concepts of Filipino
Physicians towards the Specialty. The Filipino Family Physician, July-September,
1989; Volume XXVII -, No.3: 10-12.
Goran Sjonell MD Ph.D. The Family Doctor 6 WONCA with a grant from Glaxo Group
Research Limited, 1995.
David H. Thorn MD PhD and Bruce Campbell, PhD. Patient-Physician Trust: An

Exploratory Study. The Journal of Family Practice, Volume 44 Number 2, February
1997; pages 169-176.
___________________________________________________
45

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THE

PHILIPPINE ACADEMY OF FAMILY PHYSICIANS,

PROCEEDINGS OF THE ORIENTATION

2244 TAFT AVENUE, MALATE, MANILA 1004

I. Family Medicine: History And

II. Family As A Unit Of Care

III. Family Life Cycle

IV. Impact Of Illness On The Family

V. Tools In Family Assessment

A series of events in the 1960s led to the emergence of Family Medicine.

1962 The WHO Expert Committee on Professional and Technical

1. There was a need to train family doctors to serve as physicians

1962 Folsom Committee Report (National Health Council and APHA)

1. Every individual should have a personal physician who is a

1966 Millis Commission Report (Citizen's Commission on Graduate

1. "It is time for decisive action to increase greatly the number of

1966 Willard Report (Council on Medical Education, AMA and Ad Hoc

1. "The opportunity for specialty board certification is essential for

The above-stated reasons led to a meeting of general practitioners and the

The accepted name for the World Organization of National Colleges,

Family Medicine is a discipline of Medicine with distinct core knowledge &

The characteristics of care given by family medicine are:

a. Primary first contact care at ambulatory, Emergency Room &

Prevention - all levels of prevention, with emphasis on

1961 Philippine Academy of General Practitioners was organized.

1972 Changed name to PAFP (Philippine Academy of Family

1974 First three-year residency training program was established

1979 a. First Specialty Board qualifying examination was given

1983 Research Contest started

1986 an accredited three year residency training program was

1987 Recognition of PSTFM (Philippine Society of Teachers

1990 Recognition of Family Medicine as a specialty by Medicare

1997 Recognition by PMA as the mother specialty society in the

FAMILY MEDICINE IS A SPECIALTY

1. Distinguishable body of knowledge

These criteria make Family Physicians at par with other specialists.

body of knowledge is different

2. UNIQUE FIELD OF ACTION

family-oriented health care

3. ACTIVE AREA OF RESEARCH

Family Medicine as an academic discipline is strengthened by research.

* Clinical Problems: Epidemiology of Common diseases

*Health Care Delivery: Provider characteristics

*The Family in Family Medicine Family Epidemiology

*Family Practice Approach Anticipatory Guidance

4. TRAINING WHICH IS INTELLECTUALLY VIGOROUS

strong emphasis on continuity and experience in family care

Family Medicine residency program is a 3-year program, which covers different

Projected Programs include: stronger Family Health Care, Emergency Medicine

CONTINUING MEDICAL EDUCATION FOR FAMILY PHYSICIANS IN

1. In response to the need for medical graduates to have generalist approach.

CONTINUING MEDICAL EDUCATION

FAMILY MEDICINE RESIDENCY

The bases of these competencies are experiences of Family Physicians and

FAMILY AS A UNIT OF CARE

1987 PHILIPPINE CONSTITUTION

ARTICLE II SECTION 15.

ARTICLE XIII SECTION 2.

The state shall adopt an integrated and comprehensive approach to health

SOCIOLOGIC VIEWPOINT - enduring social form in which a person is

BIOLOGIC VIEWPOINT - genetic transmission unit

PSYCHOLOGIC VIEWPOINT - matrix of personality development and the

Parsons and Bales, 1955: