-
Theoryin Actionfor GP'sFamilyMedicine
Theory inAction -A regularopportunityto explorecoreconceptsof our discipline
usingactualpatientinterviews
Presentedby Dr AnneWright and ProfessorBruceSparksfrom the
and interactionsas triggersfor discussion.
Departmentof FamilyMedicine,Universityof theWitwatersrand.
thescentr
No4. Theperson
behind
anexploration
of thesystems
approach
Thepatient's
story...
A year ago Peter and his family moved to Cape Town. Jean
was obviouslysaddenedby the move, but decidedto stay
CeliaPorter,
isthewifeof a GPcolleague
inJohannesburg. on in Pretoria."My friends are all here and I enjoy my church
groups. Of course I miss them, but they must lead their
Shetearfullypresentedlastweek stating,"lhavereached
own lives too. Anyway, it's time I shuffled off this mortal
the end of my tether.I don't know what to do. Frank's
coil".
motherhasbeenwith usfor overtwo monthsnow.andI
The patient .....
thinkI'm aboutto crack!"
The story .....
Her mother-in-law Jean Porter is 85, and until recently
livingon her own in a flat
wascomparativelyindependent,
in Pretoriasinceher husband'sdeath over 20 yearsbefore.
She was even driving her own car to the nearby shops
and the local church in her middle-class
suburb.
Six yearsago she slippedand fractured her left hip which
On
necessitatedinsertion of a Charnley prosthesis.
dischargefrom the private hospital she had a lot of pain
and disabilitywhich required a period of recuperationand
rehabilitationin her younger son Peter'shome in Pretoria.
It was not an easytime for Peter'swife Chantalwho, while
tolerating her mother-in-law'sdemanding and control Iing
attitude for Peter's sake, never really got on with Jean.
Nevertheless,within eight weeks Jean was back in her
own flat following a remarkablerecovery from her injury.
In no time she was once againdriving her old "Opel" to
andfrom the suburbanvillage.
While outwardly demonstratingan air of independence,
she relied on the frequent phone callsto Frank,and his
weekly "compulsory" visits to Pretoria to advise her on
her finances,
check her blood pressureand to move bits
of furniture to more suitablepositions. He often took his
wife Celia and their two daughters with him. The girls'
memories of Granny were of a kindly elderly woman
envelopedin Blue Grass perfume and copious amounts
of floral scented Pink Rose talcum powder, living in a flat
filledwith Englishporcelainfigurinesand dark paintingsof
Scottishclan battles. She religiouslyobserved all their
birthdayswith a card handed to Frank at least 2 weeks
beforedue date and an early morning phone call on the
day.Above all,they rememberedhow she demandedso
much of their Dad'stime.
Two months ago Jean slipped in her flat and fractured her
right hip. Againshe had a Charnleyprosthesisinserted,but
this time was dischargedto Frank and Celia's home in
Johannesburg. She recovered quite well and was soon
mobile, although non-weight-bearingand using crutches.
Despite a major second injury she was looking forward to
returningto her home in Pretoria,and even possiblydriving
again!
Then disasterstruck - and this time with what on its own
would havebeen a minor setback.One morning when she
shuffledon her own onto the front porch her crutch slipped
on the early morning dew on the highly polishedsurface.
Her fall resulted in dehiscenceof her hip wound and an
impacted fracture of her right humeral head!
She is now totally disabledand dependent on others for
every bodily function and activity,being unable to weightbear nor use her crutches.Sinceshe is a heavy,large-boned
individualshe was now confinedto her bed or wheelchair.
Celia has to attend to her every need. lt seems as though
this catastropheis the beginningof the end. Her injuries
now have major effects on the harmony in the family.
The theory....
Sowhat to do for Celial
To yourself: "l hoven'tgottime for oll this.She'sthe wifeof o
GPfor goodness
soke,'she
mustbe obleto hondleit better!
"l
ToCelia:
Elderlyporentsoreindeeda worry
understond.
ond greotburden.lcon well believehowdifficultit mustbe for
you.Speokto FronNI'm surehe hoso lotof experience
withthis
kind of problem.But to help you cope,shollwe try on
ontidepressont?
Moybeonethat'smoresedotingso
thotyoucon
"
ot leostgeto goodnrghtssleep...
And l0 minutes later,Celia is on her way with her pills.
And you're dealingwith the next influenza...
That's one way of understandingthe situation - a typical
"geriatric" case:a family suddenlyburdened with a sick,
bedridden,agedparentwith the daughter-in-law
becoming
stressedand needingmedication.
Another way of understanding
what'shappeninghere is to
use a "systems approach" or as it has come to be known,
t h e b i o p s y c h o s o c i am
l o d e l . S y s t e m st h i n k i n g a n d t h e
b i o p s y c h o s o c i am
l o d e l h a v e c o m e t o b e a c c e p t e da s
f o u n d a t i o n c o n c e p t s i n f a m i l y m e d i c i n e . rA " s y s t e m s
approach"is basedon generalsystemstheory derivedfrom
the work of the natural scientists von Bertalanffy2 and
others. General systems theory, in contrast to the
nineteenthcentury reductionistscientificmethod,which
"dealt with problems by cutting them down to size,
separatingthem from their surroundingsand reducingthem
as far as possibleto simple,linear,causalchains,seeksto
approach problems by including all their significant
relationships".3According to systemstheory,nature can
be understood as a hierarchy of systems rangingfrom
molecules to social systems.Engel'sa depiction of the
systemshierarchy is illustrated graphicallyin Figure l.
Society
0
Culture
0
Community
0
Family
0
Twoperson
0
Person
0
Nervous
system
0
Organsystems
0
Tissues
0
Cells
0
Molecules
Figurel: Systemshierarchy(from Engel1980)
Each level is both a whole and a part of a greater whole.
Thus, the family is both a whole (a system) and is also
made up of different parts or subsystems,for example,
children,marital partners,and grandparents.
As you will
notice from the double headedarrows,eachlevelisJanusfaced s, that is, it faces both in the direction of a higher
order system and toward a lower-order system. For
example,the "person" (herselfa conglomerateof various
psychologicalsubsystems)relates to the nervous system
but also to another wider system,be it a partner;family or
community.Nothing exists in isolation,interdependence
and interconnectedness is key. Despite this
interconnectedness,each level can only be explained in
terms unique to itself;for example different laws govern
molecular,cellularand personalbehaviour.Central to the
notion of wholes and parts is the concept that the whole
cannot be understood lust by understandingthe parts, as
McWhinney says,"a system has properties that are not
p r e s e n t i n t h e i n d i v i d u a lp a r t s ; t h e y a r i s e f r o m t h e
relationshipbetween parts".6 So,for example,one cannot
understandthe dynamicsof a familysimplyby knowingthe
individualmembers:thenatureof the interactionbetween
the individualsproducesa uniquedynamic.Eachsystemis
said to exist in a state of dynamic equilibrium - a "steady
state" both within itselfand with the external environment.
When this steadystate is disturbed,eventhrown into crisis,
"corrective forces" will attempt either to restore the
equilibriumor create new steadystate,"muchthe sameas
a tightrope walker keeps his or her balanceby making
f r e q u e n t s h i f t s a n d a d j u s t m e n t s " TB
. e c a u s et h e r e i s a
relationshipof interdependencebetween the wholes and
parts,a changein any one part will produce a cascadeof
effect throughout the hierarchy.
Prior to Jean Porter's first fracture the systems were in
relativebalance.Atthe community levelshe was a regular
church-goerand enjoyedher trips to the local shops,her
familywere supportivebut independent,andas an individual
she was healthy,livingin her own flat and self-sufficient.
But
her fracture which presented itself at the organ system
level could express itself upwards at every level of the
cascade,
affectingher personalwell-being,deprivedher of
good health,applyingpressuresand being dependenton
family members. Eventhe community levelis affectedwith
increasedutilization of resourcesand community services.
A t l o w e r l e v e l s o f t h e h i e r a r c h yi m m o b i l i t y r e s u l t s i n
demineralizationof bony tissues,musclewasting,weakness,
and inflammatory responsesat a cellular and molecular
level. Upon healing,a new balanceof systemswas reached
and relativenormalitywas re-established.
These features of systems were used by a psychiatrist,
George Engel,twenty years ago,to propose a "new medical
model" to replacethe dominant biomedicalone.8 In two
watershed papers he argued that the central problem of
the biomedicalmodel of diseaseis that it is reductionist,
focusingexclusivelyon biologicalfactorswith no room for
the socialand psychological
ones.Themodel he proposed
was based on general systems theory and is called the
"biopsychosocialmodel", a term now synonymouswith
"systemsapproach".Whilethe clumsynamemight suggest
that all he was proposing was that socialand psychological
factors be "added" to the medicaldataas discrete,unrelated
i s s u e s ,t h e s y s t e m sc o n c e p t s u n d e r p i n n i n gt h e m o d e l
"emphasisesinterdependencyand interplayamongdifferent
levelsof the system..(which) all interact with one another
to affect the patient who walks into a clinic with a
presentint complaint.Recognisingand acknowledgingthe
interactionbetweenthese differentlevelsof systemsallows
one to better understand those mysterious,vague or
persistentclinicalproblemsseen in day to day practice"e
Another challengeto the stability of Jean'sworld arose
when her younger son,Peter and his familymoved to Cape
Town.While this was obviouslya loss for het she balances
this againsther continuingcontact with her friends and
church- and of course.her son Frank.Thereis also a hint
that she is beginningto confront her own mortality.The
familysystem remains intact.
T h e d i s c u s s i o n. . . .
WhileFrank& Celia's
familysystemhadbeenableto
accommodateand adlust to the second fractured femur
with relatively minor cascadingeffect up and down the
hierarchy,
it was the final"minor" injury to her humerus
that had"broken the camel'sback",causingtotal immobility
for Jeanand major familydysfunctionin her son'shome.
This is illustratedin Figure2. The injury had catastrophic
effects on all levels of the hierarchy.Becausethe family
systemwas unableto "bounce back" - known as positive
feedback(which implies "an amplification of a deviation
and (which) drivesthe systeminto excess")- the situation
is madeworse. Previouslythe adjustmentsthat were made,
for exampletaking granny into their homes,had provided
negativefeedback(stabilisesa systemby reducingdeviation
from its normal range- i.e.things get back to normal)
It seemsthat the system has exhausted itself in its ability
to adjust,restore balance- there are no more internal
resources - so each new setback drives it toward
collapse.
This is where the GP consultationwith Celia could be
familyphysicianwould be able
crucial.Asystems-oriented
Event
R hip fracture and
humeralhead
to move beyond the immediate problem of the patient and
her depression,andoffer a systemsapproach.In this instance
it could be:
' a more careful exploration with the patient of the
situationwhich would includeproblemswith grannyand
also negativeeffects on the family;
' an assessment
of the difficultiesand availableresources,
both within the familyand outside,e.g.nursingcare;
' offer a family meeting/consultation;
' look to the medium- and long-term - offer ongoing
suPPort.
How can a family practitioner be more systems-oriented?
What are the availabletools for facilitating a systems
approach?
(a) Peelingthe onion: "Most medicalproblems resemble
the metaphoricalonion.When scrutinisedcloselythey
shed layerafter layer...thisdoes not mean that the outer
layersare less vivid, urgent and real than the deeper
more obscureones.Ratherit meansthat the outer level
is not the whole story and that the'onion' problem will
not be entirely resolved by attending solely to the outer
'peel
level. ... at times we may need to
the onion' to
managesymptoms unresponsiveness
to a reductionistic
view of the presentingillness"r0;
(b) Using family system theory and suggestinga family
conference?Possibleareas for doctor to explore and
observe:rl
(i) Tracking:exactly what happensregardingthe symptom
and the family?
(ii) Distress:whatare the sourcesof distressfor this patientl
For this fami|?
(iii)Cohesiveness:
how cohesiveis this familyl ls it more
enmeshedor disengaged?
(iv)Adaptability:how adaptableor rigid is this patient and
the family system;
Systemshierarchy
Community
Family
---+
Increasedutilisationof reesources,
medicalaid funds...
+
Living with Frank and family; complete dependencefor every function
Doctor-patient ---+
Person
+
Nervous system +
Organ system +
Tissue
Cell
Molecule
System changes
Celia presentswith stress
Complete dependence;in bed or wheelchair
Fustration and possible depression
Immobility, loss of "fitness", stressulcers...
+
Fracture healing
--+
Inflammatory responses
+
Deminerallisation
Figure2: lmpacton the systemsafterJean'ssecondhip fractureandfracturedhumerus
2nd
( c ) U s i n g t h e t h r e e s t a g e ( c o m p r e h e n s i v ea) s s e s s m e n t r 2 : 3 McWhinneylR.A Textbookof FamilyMedicine.
edition.Oxford: Oxford UniversityPress;1997,65.
assessing
the clinicalindividualand contextualaspectsof
McWhinneyprovidesan excellentconcisedescription
the problem;
(d) "BATHing the Patient" r3:usingfour usefulquestionsto
of generalsystemstheory and the biopsychosocial
model(pg64 - 7l).
help elicit the patient'spsychosocialsituation:
4. EngelG.TheClinicalApplication
of the Biopsychosocial
Bacllground: "What is going on in your life?"
"
"How
Psychiatry
| 980:| 37;537..
do you feel about that?
Model.American
Affecc
Journalof
"What about the situation troubles you
Trouble:
5 After Janusthe two-facedRomangod of doorwaysand
archeswho guardedthe templedoor.
2nd
6 McWhinneylR.A Textbookof FamilyMedicine.
edition.Oxford:Oxford UniversityPress;| 997,66
"The art and scienceof applyinga systemsapproachto health 7 McDanielS, Campbell
TL and SeaburnDB. Familyfor medical
providers.
OrientedPrimaryCare,a manual
careturns on the choiceof systemslevelswith which to work...
york
New
SpringerVerlag;1990,7
which areas deserve further exploration and evaluationl
Model:achallenge
G.TheNeedforaNew Medical
Which componentsmight providethe most powerful leverage 8 Engel
for biomedicine.
Science1977:196;129-136;EngelG.
treatment?"
for successful
The Clinicalapplication
of the biopsychosocial
model.
AmericanJournalof Psychiatry
1980:| 37;535-543.
The postscript ....
9 C a m p b e lTl a n d M c D a n i e S
l .A p p l y i n ga S y s t e m s
Approach
to
Common
Medical
Problems.
In:Crouch
The effects within the hierarchy are not always negativeor
MA andRobertsL.(ed)TheFamilyin MedicalPractice,
harmful.In a systemsmodel one shouldnot appoftion blame.
Primer.NewYorkSpringerVerlag;
1987,
a FamilySystems
It is a matter of reactionsand interactionswithin the system.
|2
In a subsequentdiscussionwith Frank,hesaysthatthere have
Viewof the ClinicalRelationship.
in
| 0 SteinH.A Systems
been some very positive effects from Jean's injury. Both
CrouchMA andRobertsL.(ed)The Familyin Medical
grandchildrenhavetaken an active role in supportingtheir
Primer.NewYork Springer
granny,and have at last begun to understand and share
Practice,
a FamilySystems
I
Verlag;1987,3
meaningfultime with the'person behindthe scent'.
| | RobertsL.FamilySystemsTheory
in MedicalPractice.
In CrouchMA andRobertsL.(ed)TheFamilyin Medical
The library ...
Primer.NewYork Springer
Practice,
a FamilySystems
I See for example,McWhinney lR. A Textbook of Family
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GSandHenbestRJ.InSearch
of Excellence.
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the Patient-Centred
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Three-stage
assessment.
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l 3 L i e b e r m a nJ A a n d S t u a r t M R . P r a c t i s i n g
(ed)The Fami| in MedicalPractice,aFamilySystemsPrimer.
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In:RakelRE(ed).Textbook
Biopsychosocial
NewYork SpringerVerlag;
| 987.
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a :B
o f F a m i l yP r a c t i c e5. t h e d i t i o n .P h i l a d e l p h iW
Braziller;1968
S a u n d e rCso m p a n y , 5-56 l .
Empathy:
the mostl "
"That mustbe very difficultfor you"
"Nurse,pleasego to surgery.com
and clickon the little helpbutton."