From 911 to 1226: What Family Physicians can offer?

W W Lam 林永和

People all over the world were haunted by the devastating tsunami which happened on the 26th of December last year. Tens of thousands of families were broken and many thousands of surviving children turned to be orphans overnight. Some survivors are mourning the death of their loved ones while many others are still desperately searching for their missing loved ones, or bodies. With such a large scale disaster, thousands of organizations are providing relief and rebuilding works in the affected areas. Fund raising campaigns have been running at unprecedented levels around the world. Experts from different disciplines are collaborating in the recovery works. They try to minimize the possible aftershocks like foodborne and waterborne diseases. Another aftershock started to be aware of by experts over the world is the mental health toll of the tsunami. While this disaster not only impinges on survivors in the affected areas, many people around the world are shocked and wrenched by the staggering death count, the photos and the video. By the time you read this editorial, it is a month after the disaster. It is time for us as family physicians to think further our roles during the time of disaster.

A family physician is described as a physician who personally provides whole-person health care to individuals and families in their living environment.1 There are four core elements characterizing our discipline, namely, a particular approach to patient-centredness, particular skills in primary assessment and management of presenting problems, a responsibility for delivery of comprehensive care and a particular role in health promotion or disease prevention.2 Despite the fact that evidence-based medicine and advanced technology facilitate us in making many clinical decisions these days, the rapport building skills and proficient communication techniques are still central to a successful treatment. Those skills are the prerequisite of having accurate assessments, negotiating diagnoses and management with patients, delivering useful information, providing counselling and nurturing the doctor-patient relationship. In the same vein I find that family medicine training has already equipped us with the frame of mind, the expertise and relevant skills to face the greater than ever challenges in the frontline of our health care system. One of the challenges today is to minimize the mental toll of critical incidents like those in our recent history - Lan Kwai Fong Incident, the outbreak of Severe Acute Respiratory Syndromes (SARS), 911 Attack and the devastating tsunami this time. We as family physicians should accept challenges ahead and take up a role to lead the community in the time of disasters.

Stress is a universal experience in everyday life. Whether an event is perceived as stressful depends on the nature of the event, the person's resources, psychological defenses and coping mechanisms.3 Disasters denote an extreme stressor that inflicts on those directly affected and/or indirectly affected. The majority of people develop transient stress reactions that can be resolved without intervention. However, a certain percentages of people, depending on the vulnerability and genetic predisposition, will develop various kinds of psychiatric disorders.4 Post-traumatic stress disorder (PTSD) is the most significant amongst them. It usually develops within 3 months after the trauma but there can be a delay for months and years.5 PTSD is frequently a chronic and disabling disorder but it can go into remission with early treatment.6 In a survey of Manhattan residents conducted 5 to 8 weeks after the World Trade Center collapse, it was found that 9.8 percent (90,000 people) had PTSD or clinical depression and another 3.7 percent (34,000 people) met the criteria for both diagnoses.7 Therefore, it is high time for us in the frontline to identify those being affected by the tsunami and engage them into proper treatments early.

Distressed patients are usually looking for people to talk to and family physicians are the primary and vital source of help since the distress is frequently a mixed condition of physical symptoms, emotional turmoil and psychological impairment.8 By taking a proactive role to ask patients about their reactions to the disaster, we are inviting them to express their feelings and encouraging them to seek help. Proper screening and assessment of different psychiatric disorders should take place and corresponding treatments should then be commenced. Active listening, empathy, support, psychoeducation and advice on stress management are beneficial to all distressed patients and may suffice for mild stress reactions. Various anxiety and depressive disorders can effectively be treated with antidepressants and judicious use of anxiolytics. The importance of arranging regular consultations for patients with emotional problems should not be overlooked because we need to follow up and reassess their conditions from time to time. Their family members should also be screened for coping problems. In fact, family members are always an important source of support to patients and rich informants to physicians.

Referral may be considered for patients who are severely distressed, with PTSD, with significant psychosocial maladjustments, and with other complications such as substance abuse problems. Making referral does not denote the end of the treatment from the viewpoint of a care-provider. Instead, it signifies the start of playing our role as a coordinator and a resource manager. Beyond the consultation room, we can take up community-based works such as delivering health talks to the general public. This is one of the preventive measures that we can actively participate in.

At the college level, our president Dr John Chung has solicited donations from all members. Also, he advocated us to offer support and counselling to those having sleep problems, excessive sorrow and emotional drain due to the exposure to the tsunami related news. Our college consists of approximately 1,600 doctors working in the government and private sectors. The coverage is so broad and the service is easily accessible to the general public. Therefore, our timely and concerted efforts can amount to a significant benefit to society. The seminar that was organized shortly after the tsunami further equipped us to meet the challenges. More courses on psychological treatments have been devised to enhance our psychological intervention skills so as to consolidate our role as a counselor.

Keeping ourselves hale and hearty is the precondition to help others. Our mottoes to patients are - keeping a healthy lifestyle, saying no to drugs, doing regular physical exercise, having a balanced diet and upholding the sleep hygiene. To what extent we can adhere to the above? Besides, we need to have outlets to unload our frustration and fatigue stemmed from the process of treating those with emotional disturbances. It is because a gradual accumulation of patients' distresses can exert subtle to pernicious effects on our attitudes, emotional states, the sense of wellbeing and the view of the world.8 Last but not least, we should have a self-awareness to strike a balance among the constituents of our lives including work, family, friendship, self-fulfillments, spiritual needs and community responsibilities.

"Adversity draws men together and produces beauty and harmony in life's relationships; just as the cold of winter produces ice-flowers on the window-panes, which vanish with the warmth." by Sren Aaby Kierkegaard (1813-55), Danish philosopher.