Perkel Rl

Family systems intervention and physical illness.

Family systems theory provides the physician with a comprehensive paradigm to investigate the social and interpersonal context of physical illness. All physical illnesses, particularly life-threatening and chronic ones, profoundly affect the family life of the patient, and the changed family circumstances in turn have impact upon the physically ill patient. This reciprocal interaction between the illness and the family system varies according to the onset, course, outcome, and level of disability. This paper discusses the general application of family systems theory to physical illness as well as the description of the family dimension of acute life-threatening illness, AIDS, chronic illness, chronic neurologic disease, dementia, chronic pain, and cancer in children. We propose that an operational knowledge of theoretical concepts and technical competencies of family systems theory can enhance the therapeutic reach of physicians and other health professionals.

THE IMPORTANCE OF ADVANCE DIRECTIVES IN PRIMARY CARE

The advance directive has been acknowledged widely by patients and physicians as a desirable tool to promote patient autonomy at the end of life. Rates of completion of advance directives, however, remain low among all segments of the population. Significant patient and physician barriers to completion of advance directives are considered. Legal and ethical principles of advance directives, as well as some practical means of overcoming barriers to these important discussions, are reviewed.

ETHICS AND MANAGED CARE

Managed care presents physicians with potential ethical dilemmas different from dilemmas in traditional fee-for-service practice. The ethical assumptions of managed care are explored, with special attention to the evolving dual responsibilities of physicians as patient advocates and as entrepreneurs. A number of proposals are described that delineate issues in support of and in opposition to managed care. Through an understanding of how to apply basic ethics principles to managed care participation, physicians may yet hold on to the basic ethic of the fiduciary doctor-patient relationship.

A house call program as an essential component of primary care training.

Despite the decline in the frequency of house calls by physicians during the twentieth century, such activities generally have been accepted as valuable and desirable by physicians and continue to be a feature of primary care practice. As the economic basis of health care undergoes significant changes in the era of managed care, the future viability of home visits by medical practitioners similarly hangs in the balance.