Page 6 - The SA Journal Diabetes & Vascular Disease Volume 9 No 4 (November 2012)

148 VOLUME 9 NUMBER 4 • NOVEMBER 2012
REVIEW SA JOURNAL OF DIABETES & VASCULAR DISEASE
The role of the family physician in caring for the patient
with diabetes
N NAIDOO
Correspondence to: Dr N Naidoo
Greys Hospital, Pietermaritzburg and New Hanover,
KwaZulu-Natal
e-mail:docnn@iafrica.com
S Afr J Diabetes Vascular Dis 2012; 9: 148–152
Introduction
The governing principles and the scope of practice of family
medicine is in keeping with the South African Government’s vision
of transforming or re-engineering the primary healthcare (PHC)
system, especially the envisaged role of the family physician in the
district healthcare team. The family physician should have a central
role in the achievement of quality, cost effectiveness and equity
in healthcare systems. The family physician can therefore play a
vital role in improving our PHC services and contribute towards the
provision of appropriate, easily accessible and continuous care at
the district level.
To fulfil this responsibility, the family physician must be highly
competent in patient care and must integrate individual and
community healthcare.1 Cooperation between the World Health
Organisation (WHO) and the World Organisation of Family Doctors
( WONCA) towards this vision is historic. The WHO and WONCA in
1995 put out a report titled: ‘Making medical practice and education
more relevant to people’s need: the role of the family doctor’. From
1998 to 2001, 14 strategic action plan initiatives were proposed to
achieve this. Efforts to improve the quality and comprehensiveness
of primary care, especially care delivered by the family doctor are
emerging worldwide.2
In South Africa, family medicine has now achieved the position of
a clinical speciality, through a nationally agreed training programme
involving all eight medical schools, with training sites in both urban
and rural areas. Family medicine departments are set up in specific
districts and family medicine posts are created and filled at district
hospitals.1
With regard to managing non-communicable diseases, and in
particular diabetes, the family physician’s role is typically that of
the so called ‘five-star doctor’. This reflects the multiple role of the
family doctor, namely care provider, decision maker, communicator,
community leader and manager of resources for the benefit of the
patient, the practice population and the community served.1
The nine guiding principles of family medicine were well
described by Prof Ian Mc Whinney in the 1970s.3 Essentially this
entails providing personalised or patient-centred care, preventative
and promotive care, continuity of care, comprehensive and
integrative care, cost-effective care, and easily accessible care for
any condition or illness at any time and at any place. The family
physician always takes into account the context and subjective
aspects of the presenting problem and manages the resources to
the benefit of the patient. Behavioural, social, environmental and
cultural aspects are always considered when providing care and
making assessments.
The practice population is always viewed as a population at
risk. Family medicine forms an important link between the social
sciences and the counselling professions.
Although diabetes does not attract as much attention currently
as the new chronic disease, HIV/AIDS, the complications associated
with diabetes are devastating and crippling, and have a major
impact on morbidity, mortality and healthcare resource utilisation.
Diabetes is already a major cause of death in South Africa, afflicting
about 8–10% of the population. The number of persons with
diabetes in all districts in KwaZulu/Natal since 2005 appears to have
overtaken the number of HIV/AIDS cases in the province. 4
This should have important implications for resource allocation for
non-communicable diseases in the province and the establishment
of non-communicable disease clinics, as has been done for
communicable diseases. It has been of great concern recently to
notice that some hospitals have closed their diabetes and chronic
diseases clinics, which had been in operation for many years. This
will have serious consequences on optimal diabetes care and lead
to poor patient outcomes.
The current status of diabetes care
The realities that confront many family physicians, especially in a
working-class family practice where the majority of patients use
public service clinics or hospitals and many do not have prepaid
medical cover, is that most patients have established complications
involving target organs at the time of diagnosis as they often
present late or have aggressive diseases. This also applies to
diabetic patients attending some academic hospital clinics. This
poses great challenges for the family physician and other doctors
and specialists treating the diabetic patient. Currently, the majority
of these patients with diabetes (about 40 to 60%) receive sub-
optimal care.
An analysis of some research studies on patients attending
diabetes clinics in South Africa confirms that a large number of
patients receive sub-optimal control, and highlights several reasons
for this:5-8
Poor adherence to lifestyle issues, such as dietary advice, alcohol •
usage, regular exercise or physical activity, smoking cessation
and weight loss.
Late presentation and many patients have established •
complications at the time of diagnosis.
Poor patient education and lack of health professional education •
and training in diabetes care.
Inadequate patient self-control and monitoring. •
Poor adherence to current and accepted guidelines for diabetes •
management.