全科医学教学课件：第6讲 The Family in Health and Disease

TheFamilyinHealthandDisease

P229-260ContentsIntroductionWhatIsaFamily?RecentChangesintheStructureandFunctionoftheFamilyWhatdoesitmeanto“ThinkFamily”TheInfluenceoftheFamilyonHealthandDiseaseTheFamilyLifeCycleDevelopmentaltasksTheTraumasofFamilyLifeHowFamilyDoctorsWorkwithFamiliesPreceptsofFamilyCareDiscussionsIntroductionTheimportanceofthefamilytofamilyphysiciansisinherentintheparadigmoffamilymedicine.Familymedicinedoesnotseparatediseasefrompersonorpersonfromenvironment.Itrecognizesthestrongconnectionbetweenhealthanddisease,andpersonality,wayoflife,physicalenvironment,andhumanrelationships.ItunderstandsthestronginfluencethathumanrelationshipshaveontheoutcomeofillnessandrecognizesthefamilyasthecrucibleofthedevelopmentofthepersonFourlevelsofphysicianinvolvementwithfamiliesThefirstBeminimalinvolvement.ThesecondBetheprovisionofinformationandadvice.thephysicianhastobeopentoengagingfamiliesinacollaborativewaytakingcaretocommunicatemedicalfindingsandtreatmentoptionstofamilymemberslisteningattentivelytotheirquestionsandconcerns.Thisdoesnotrequirespecialknowledgeoffamilydevelopmentorreactionstostressfulexperiences.Thephysicianatthethirdlevelincludestheabove,butalsohasanunderstandingoftheaffectiveaspectsoffamilyrelationships.Thephysicianisthereforeabletoprovideemotionalsupporttohelpfamilymembersdealwiththefeelingsarousedbyhavingafamilymemberwithillnessessuchascancer,schizophrenia,diabetes,andphysicaldisability.Topracticeatthislevel,thephysicianneedsaknowledgeoffamilydevelopmentandofhowfamiliesreacttostressfulexperiences.beaskilledlistener,responsivetothesubtlecuesbywhichemotionalneedsareexpressed.Alsoneededisenoughself-knowledgetobeawareofhowthephysician’sownfeelingsaffecthisorherrelationshipwiththepatientandfamily.Atthefourthlevelthephysiciancancarryoutasystematicassessmentoffamilyfunctionplananinterventiondesignedtohelpafamilydealwithitsproblems.Thiswilloftenincluderefraimingthefamily’sdefinitionoftheproblemencouragingthemtoconsidernewwaysofcopingwiththeirdifficulties.Topracticeatthislevel,thephysicianneedsanunderstandingofsystemstheorytheskillsofconveningandconductingafamilyconference.ThismayincludeengagingfamilymemberswhoarereluctanttoparticipateandencouragingpoorlycommunicatingfamilymemberstoexpressthemselvesFamilytherapyLevelsthreeandfourmustbedistinguishedfromfamilytherapywhichisbasedontheideathattheidentifiedpatientisa“symptom”offamilydysfunction.Therapyisthereforedirectedtowardthewholefamilysystem.Atlevelsthreeandfour,amemberofthefamilyissickandthephysicianishelpingthefamilytocareforthepatient.Ofcourse,thelevelsmayoverlapwithfamilytherapy.Afamilywithasickmembermayalsobedysfunctional;butfamilyphysicianswillmostlybehelpingordinaryfamiliesmobilizeresourcestoimprovetheircopingskillsFamilymedicineandfamilytherapyConfusionhasarisenfromtimetotimebetweenfamilymedicineandfamilytherapy.Infamilytherapy,thephysiciancancarryoutaplannedcourseoftherapyforadysfunctionalfamily.Thephysicianrequirestheinsightandskilltointerveneinsuchawayastochangethewaythefamilyfunctions.Thefewfamilyphysiciansworkingatthislevelaretrainedfamilytherapistswhocombinetherolesoffamilyphysicianandfamilytherapist,someofthemreceivingreferralsfromotherfamilyphysicians.“Thepersoninthefamily”and“thefamilyintheperson.”Thepersoninthefamilyrepresentstheinterpersonalrelationshipsinthefamilygroup.Thefamilyinthepersonrepresentstheindividual’sincorporatedexperienceofhisorherfamilyoforigin-anexperiencethatprofoundlyaffectsself-conceptandrelationshipswithothers.Apersonisraisedandnurturedinafamilyfortheearlyyearsoflife,butthefamilyremains“in”thepersonuntilhisdeath.Learnedto“thinkfamily”inthetrainingOfcourse,familyphysiciansarenottheonlyclinicianswhohavethisunderstandingofthefamily.Otherphysicians,especiallythoseprovidinglong-termcare,mayworkwithanawarenessofthefamilycontext.Familyphysicianscannotclaimtobethesolepossessorsofthisknowledge.Whetheraphysiciandoesso,however,islargelyamatteroftraining.Aphysicianwhohasnotlearnedto"thinkfamily”inhistrainingisnotlikelyto“thinkfamily”inpractice.Forexample,Ididnotevenmaketheconnectionbetweensevereheadachesinayoungmanandthefactthathischildhadmusculardystrophy.Itwasnotformanyyearsthat,undertheinfluenceofacademicfamilymedicine,Idevelopedsomecapacityfor“thinkingfamily.”Otherphysicianscanworkwithfamilies,butthefactisthatoutsidefamilymedicine,fewaretrainedtodoso.Case10.1Ayoungmarriedwomanwithnochildrencametoseemewithlowerabdominalpains.Becauseshehadpreviouslyhadanectopicpregnancy,thiswassuspectedatfirst.Observationinthehospitalwassufficienttoexcludethisdiagnosis.Thepainscontinued,however,anditbecameclearthatthepatientwasgoingthroughaseveremaritalcrisis.Duringthesameweek,herhusbandcametoseemewithintercostalmusclepainandherfatherattendedwithdepression,neitherofthemconnectingtheirproblemswiththefamilysituation.Theillnessesofhusbandandfathertookonanewmeaninginthecontextofthecrisisinthefamily.Thecrisiscametoaheadinthesameweekwiththeseparationofhusbandandwife.Thepictureofafamilyobtainedthroughtheeyesofoneofitsmembersisoftenverydifferentfromthepictureobtainedfromthephysician’spersonalknowledgeofotherfamilymembers.Thisderivesfromtherealitythatthefamilyexperienceisdifferentforeachmemberofthefamily.Acceptingwithoutcorroborationtheversiongivenbyonefamilymemberisoneofthemostcommonpitfallsforthefamilyphysician.Itcouldstillbemaintainedthatthisknowledgeandtheseskillsarenotuniquetofamilymedicine.Aninternistcouldcareforafamilywithadultmembersinexactlythesameway.Ofcoursehecould,andhewouldbefunctioningasafamilyphysician.Thenameandtheacademicpigeonholearenotreallyimpor­tant.Inpractice,however,Istilldoubtwhethermanyphysiciansoutsidefamilymedicinearetrainedtothinkandpracticeinthisway.FamilyValuesInWesterncountrieswetendtoassumethatthenormswetakeforgrantedinhumandevelopmentandfamilyfunctionareuniversal.Westernassumptionsaboutthevalueofindividualautonomy,andtheneedtoraisechildrentobeindependentareforeigntotheculturesofIndia,Japan,andmanyothercountries.ChildrearinginIndiaandJapan,forexample,fostersdependenceandinterdependence.Indiaisa“highcontext”society.WhatIsaFamily?Thechangingnatureofthefamilyinindustrialsocietieshasledsometoquestionwhethertheideaofafamilyphysicianisstillappropriate.Theerrorhereistoidentify“family”withaparticularkinshipgroup,suchastheso-callednuclearfamilyoffather,mother,andchildren.Ifafamilyisdefinedasagroupofintimateswithbothahistoryandafuture,thentheactualstructureofthegroupmayvarywithoutchangingitsessentialfunction.Thedeclineoftheextendedfamilyinmanyindustrializedsocietieshasbeenoveremphasized.Itistruethatmanyfamiliesbecomewidelyscattered,butmodemcommunicationsmakeitmucheasierforfamilymemberstoremainintouchwitheachother,andtocometogetherattimesofcrisis.Itisnotunusualnowadaysforfamiliestocometogetherfromtheendsoftheearth.RecentChangesintheStructureandFunctionoftheFamilySincethe1960s,bigchangeshaveoccurredinthecomposition,activities,andeconomicstatusoffamiliesinmostWesternindustrializedsocieties.Becausemanyofthechangeshavebeendislocating,theirimpacthasbeenfeltinthekindofhealthproblemsencounteredbyfamilyphysicians.Fragilefamilies,buffetedbyadversesocialandeconomicforces,havebecomeasourceofthe“newmorbidity”:spousalandparentalviolence,sexualabuse,parentalneglect,developmentalandlearningdisabilities,substanceabuse,emotionaldistress,andprematureparenthood.Therearelinksbetweeneconomictrendsandthesechangesinfamilycompositionandstability.Highratesofunemploymentandlowerearningcapacityamongmalesareassociatedwithlowermarriagerates,morebirthstosinglewomen,andincreasedlikelihoodofmaritaldisruption.PovertyandfamilyfunctionTherelationshipbetweenpovertyandfamilyfunctionisacomplexone.Astrongfamilyinastableandsupportivecommunitycanmitigatemanyoftheadverseeffectsofpoverty.Ontheotherhand,povertycanweakentheabilityofafamily’sabilitytocarryoutitsnurturingfunctions.Povertyisassociatedwithpregnancyinpoorlyeducatedyoungsinglemothers,whohaveneithertheearningcapacitytoprovidefortheirchildrennortheparentingskillstocareforthem.Farfromhavingsupportivecommunities,theyarecondemnedbytheirpovertytolivinginviolentandsociallydisorganizedneighborhoods.Whatdoesitmeanto“ThinkFamily”“Thinkingfamily”isbeingsensitivetotheunmentionedfamilystressesthatoftenliebehinddepressionandsomaticsymptomssuchasheadaches,dyspepsia,orrecurrentabdominalpain.Itisalsobeingawareoftheeffectsonthefamilysystemofthephysician’sownactions-admittingsomebodytothehospital,makingaseriousdiagnosis.“Thinkingfamily”isbeingawareofsomeofthetrapsthatawaittheunwaryphysician:beingenlistedbyonesideofafamilyconflict,acceptingthefamily’sviewsofatroublesomeadolescent,disclosingtootherfamilymembersinformationthatshouldbeconfidential.Whatdoesitmeanto“ThinkFamily”TheInfluenceoftheFamilyonHealthandDiseaseThefamilyhassixmaineffectsonthehealthofitsmembersGeneticInfluencesTheFamilyisCrucialinChildDevelopmentParentaldeprivation;Respiratorydisease;Intestinalinfections(streptococcalfamilies,staphylococcalfamilies);Accidents;Nonfebrileconvulsions;Enuresis;ChildrenwithbehavioraldisturbanceSomeFamiliesAreMoreVulnerabletoIllnessthanOthersInfectiousDiseaseSpreadsinFamiliesFamilyFactorsAffectMorbidityandMortalityinAdultsTheFamilyIsImportantinRecoveryfromIllnessTheFamilyLifeCycleFamilyLifeCycleStage-critical

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cycleStageoftheFamilyLifeCyclePositionsintheFamilyStage-CriticalFamilyDevelopmentalTasks1.MarriedcoupleWifeHusbandEstablishingamutuallysatisfyingmarriageAdjustingtopregnancyandthepromiseofparenthoodFittingintothekinnetwork2.ChildbearingWife-motherHusband-fatherInfantorbothdaughterorsonHaving,adjustingto,andencouragingthedevelopmentofinfantsEstablishingasatisfyinghomeforbothparentsandinfants3.Preschool-ageWife-motherHusband-fatherDaughter-sisterSon-brotherAdaptingtothecriticalneedsandinterestsofpreschoolchildreninstimulating,growth-promotingwaysCopingwithenergydepletionandlackofprivacyasparents4.School-ageWife-motherHusband-fatherDaughter-sisterSon-brotherFittingintothecommunityofschool-agefamiliesinconstructivewaysEncouragingchildren’seducationalachievement5.TeenageWife-motherHusband-fatherDaughter-sisterSon-brotherBalancingfreedomwithresponsibilityasteenagersmatureandemancipatethemselvesEstablishingpostparentalinterestsandcareersasgrowingparents6.LaunchingcenterWife-mother-grandmotherHusband-father-grandfatherDaughter-sister-auntSon-brother-uncleReleasingyoungadultsintowork,militaryservice,marriage,etc.,withappropriateritualsandassistance7.Middle-agedparentsWife-mother-grandmotherHusband-father-grandfatherRebuildingthemarriagerelationshipMaintainingkintieswitholderandyoungergenerations8.AgingfamilymembersWidow-widowerWife-mother-grandmotherHusband-father-grandfatherCopingwithbereavementandlivingaloneClosingthefamilyhomeoradaptingittoagingAdjustingtoretirementDevelopmentaltasksInassumingadevelopmentaltask,anindividualmustperceivenewpossibilitiesforhisorherbehaviorformnewconceptionsofselfcopeeffectivelywithconflictingdemandshavethemotivationtoachievethenextstageinhisdevelopment.TheTraumasofFamilyLifeTheEffectsofInadequateParentingConflictDivorceIllnessandDisabilityBereavementPovertyUprootingUnemploymentTheopportunitiesaredressedintroubleThankyouforgivingmethelove,it’sunforgettableallmylifeHowFamilyDoctorsWorkwithFamiliesAlthoughafamilyphysicianmaynotbeabletoactasfamilytherapistinhisorherownpractice,heorshecanhelpselectedfamiliesbyreferringthemforfamilytherapy.Manyfamilies,however,areresistanttofamilytherapy,lackingeventherecognitionthattheyhaveaproblem.Familyphysiciansstillhavetoworkwiththesefamiliesasbesttheycan.TheFamilyConferenceTheconferencecandealwithbothcognitiveandaffectiveissues.Providinginformationtothewholefamilytogethercanminimizetheriskofmisinformation,especiallyifquestionsareinvitedandrespondedtowithcare.Theconferencecanprovideanopportunityforfamilymemberstoexpressfeelingsthattheyhavefounddifficulttoexpressbefore.Withgoodlisteningskills,thephysicianmaypickupcuestofamilyconflictsortoafamilymemberwhoisespeciallyvulnerable.Thismay,forexample,beamemberwhositssilentthroughouttheconference,oronewhodoesnotattendatall,eventhoughheorsheisreadilyavailable.PreceptsofFamilyCare1. Lookoutforvulnerablefamiliesandgivethemextrasupport.2. Providegoodinformationattimesofseriousillness.Ask,“Haveyouanyquestions?”3. “Bethere”attimesofcrisis:seriousillness,terminalillness,bereavement.4. Taketheinitiativeattimeswhenyoumaybeneeded-ondischargefromthehospital,forexample.Don’tassumepeoplewillknowwhentocall.5. Lookoutforvulnerablefamilymembers,the“hiddenpatient.”6. Lookoutforpatientswhoarefamilyscapegoatsorpresentingsymptomsofafamilyproblem.7. Avoidbeingdrawnintotakingsidesinfamilyconflicts.8. Offerafamilyconferenceatcriticaltimes.TheUniversalImportanceoftheFamilyThepublichealthservicescanimprovethemacroenvironmentbyinstitutingwatersupply,refusedisposal,pestcontrol,foodhygiene,andsoforth.Butitisthemicroenvironmentinthehomeanditssurroundingsthataremostimportanttothechild.Thesearecontrolledbytheparentsanddependontheirvaluesandtheirdiligence.Whetherinrichorpoorcountries,"developed"or"developing,"thehealthofindividualsisinfluencedbyfamilylife,andfamiliesareaffectedbytheillnessesandmisfortunesoftheirmembers.Topics1.Familyrelationshipshaveinfluenceontheoutcomeofillness2.Family:Anytwopluspeoplesharinglife3.Doctorsshouldspend15minutesoneverypatient,10tolisten,5toexamine4.UpdateyourknowledgebyInternet5.TheNobelPrizeinPhysiologyorMedicine2013

TheNobelPrizeinPhysiologyorMedicine2013Howcargo(物质)istransported(运输)inthecell

Inalargeandbusyport(港口),systemsarerequiredtoensurethatthecorrectcargoisshippedtothecorrectdestinationattherighttime.Thecell,withitsdifferentcompartmentscalledorganelles(细胞器),facesasimilarproblem:cellsproducemoleculessuchashormones(激素),neurotransmitters(神经传导物质),cytokines(细胞因子)andenzymes(酶)thathavetobedeliveredtootherplacesinsidethecell,orexportedoutofthecell,atexactlytherightmoment.Timingandlocationareeverything.Miniature(微型的)bubble-like(气泡状)vesicles(囊泡),surroundedbymembranes,shuttle(往返)thecargobetweenorganellesorfusewiththeoutermembraneofthecellandreleasetheircargototheoutside.Thisisofmajorimportance,asittriggers(诱导)nerveactivationinthecaseoftransmittersubstances,orcontrolsmetabolism(代谢)inthecaseofhormones.Howdothesevesiclesknowwhereandwhentodelivertheircargo?NewEnglandJournalOfMedicine

WhichofthefollowingsaretoplevelinvolvementforthebestGPswithfamilies?ProvisionofinformationandadviceEngagingfamiliesinacollaborativewayTakingcaretocommunicatemedicalfindingsandtreatmentoptionstofamilymembersListeningattentivelytotheirquestionsandconcernsUnderstandingoftheaffectiveaspectsoffamilyrelationshipsProvideemotionalsupportHelpfamilyme