Introduction Health has been lost in the current healthcare system, replaced by a near exclusive focus on discrete diseases. People feel healthy if they perceive a relative balance between their physical, emotional, social and cognitive experiences. The role of the healthcare system, therefore, must be to facilitate a rebalancing of these domains in those who experience illness, regardless of the presence or absence of identifiable discrete biomedical conditions. Looking at health from a community epidemiological perspective highlights that the experience of health follows a Pareto distribution (although known as the 80:20 split). The majority of people are healthy enough not to require health care. Of the 20% who perceive to require health care, the majority require primary and community care, with very few in need of tertiary hospital care. This article reflects on the notion of health, highlighting that health is a subjective and dynamic state. Conclusion Combining these two strands leads to the conclusion that health care must focus on people and their health (and illness) experiences. A healthfocused healthcare system will be aligned to provide the structures and functions that allow people to regain their personal health, defined by their own subjective experience. Introduction ‘...The principal conception of medicine, health, and disease are necessarily related to, and acquire their meaning from, the epistemological features of clinical interaction. Both health and disease are essential conceptions of medicine as a discipline. To the objection that health and disease are definientia only of organ systems, one must counter with the large body of evidence that both concepts are evaluative; that is, they include in their meaning the values of patients, societies, and cultures (Pellegrino & Thomasma1, p63)’. ‘The way we speak is the way we think’2. Metaphors are the means to express our deeper thoughts and understandings2. In regard to health we speak, i.e. think, in military – battle against death, war against various diseases and medical care proceeding along hierarchical lines of command and control, or economic metaphors – patients are consumers and covered lives, the main concerns of health care are efficiency, profit maximisation, customer satisfaction and the bottom line3. Both metaphors indicate that almost all in the health system are fixated on the inverse of health – disease. One, therefore, may conclude that health is not the concern of medicine as an institution, or of doctors and other health professionals as the providers of care at the grass roots level. Furthermore, should health professionals even concern themselves with health, as, after all, they are trained to deal with diseases? The current perception of health and disease as separates and opposites is deeply grounded in the dichotomous reductionist worldview of the 17th century. Either–or approaches characterise the old paradigm, which fails today’s patients, professionals and society at large. The 20th century paradigm of wholism (Table 1a) views all phenomena as interconnected and interdependent—health and disease mutually co-exist at the same time in the same person. Patients experience the clash of these two worldviews especially when moving between the primary and secondary care system, as is illustrated by two common statements: ‘Everyone was interested in my heart/knee/etc., but no one was interested in me!’, and ‘Now I feel worse than before going to hospital, even though they all told me that I’m fixed’. The aim of this critical review is to give an overview on physical, emotional, social and cognitive aspects of health. Th ink health Before proceeding, it is necessary to consider what we mean by health. The term health arose from the old English word ‘hal’ meaning ‘whole’; health is wholeness, and a person being healed is one who has ‘become whole’ again. Health is a subjective evaluative state with its own dynamics, and health is an adaptive state changing over time4–8. Health is associated with physiologic changes within homeostatic boundaries9, rapid rise in resilience over the first two to three decades of life followed by a slow decline over the next 40–80 years10,11, with death occurring at a point when physiological reserves diminish to less than 20% of basal levels where everyday perturbations of life can no longer be withstood10. In addition health has an overarching purpose, being the driver of survival and reproduction5,12. Health cannot be defined by precise axioms – health is an interpretive framework; it describes * Corresponding author Email: jp.sturmberg@gmail.com 1 Monash University, Melbourne, Australia 2 The Newcastle University, Newcastle, Australia H ea lth C ar e De liv er y
Abstract Introduction Diabetes mellitus is a major chronic disease burden and is the underlying aetiology for the majority of mortality and morbidity such as renal failure and amputation. Many organizations including the World Health Organization have issued diagnostic criteria for diabetes based on four abnormalities, which include fasting glucose, random glucose with symptoms, oral glucose tolerance test and haemoglobin A1c. The main focus of diabetic management continues to be glycaemic control as determined by haemoglobin A1c levels as well as by a new marker, GlycoMark®. Glycaemic control can be improved by reduced glucose variability, which can be determined with frequent blood glucose check and/or continuous glucose monitor. Insulin (either basal–bolus or insulin pump) continues to be the recommended medication for glycaemic control for type 1 diabetes. In recent years, there have been numerous insulin pumps available in the market that can be used for type 2 diabetes as well. In addition to insulin and the pump, type 2 diabetes also has nine other oral classes of medications. There are two classes of injectables (glucagon-like peptide-1 and pramlintide), which can also be used for type 2 diabetes. Regardless of the therapy agents, all types of diabetes need lifestyle modifications including diet and exercise as first-line therapy. These different treatment modalities can be combined for high insulin-resistant diabetes as well as for difficult-to-control patients. Insulin (U-100) remains the gold standard for the management of all diabetic patients. Insulin can be classified according to their duration of action (short acting, intermediate acting and long acting). With very highly resistant diabetics, there is also more concentrated insulin (U-500). The aim of this review is to assess the different techniques used to manage diabetes mellitus. Conclusion Although insulin pumps are generally reserved for type 1 diabetes, they can be used for these highly insulinresistant patients. Another consideration is the use of continuous glucose monitoring.
Introduction In evaluating a patient with haematuria, the primary care physician must answer the following three questions: 1. Is it really haematuria? 2. Should this patient with haematuria, be further evaluated, and if so, how? 3. Should this patient with haematuria, be referred to a specialty, and if so, to which specialty? The aim of this critical review is to discuss whether family physicians should evaluate and manage haematuria. Discussion Haematuria must be confirmed by a microscopic examination. Complete urological work-up entails assessment of renal function, urine culture, upper urinary tract imaging usually with computer tomography urogram and a referral to urology for cystoscopy. If a renal disease is suspected, suitable laboratory studies followed by a referral to nephrology, is appropriate. Conclusion While most patients with haematuria will undergo urological work-up to some degree, it is important to efficiently recognise those patients, who are at a minimal risk of serious underlying urologic condition for whom detailed work-up is not necessary, those patients who are at a high risk for whom a complete work-up with cystoscopy is warranted, and those patients with likely renal causes for whom a nephrology referral is prudent. Introduction In evaluating a patient with haematuria, the primary care physician must answer the following three questions: 1. Is it really haematuria? 2. Should this patient with haematuria be further evaluated, and if so, how? 3. Should this patient with haematuria be referred to a specialty, and if so, to which specialty? This critical review addresses these questions. Because few studies have good evidence, the recommendations are mostly based on expert consensus. Discussion Is it really haematuria? Gross haematuria Gross haematuria is defined as urine that is visibly discoloured by blood. It may occur with as little as 1 ml of blood in 1 l of urine. Because patients can recognise the abnormal colour of the urine, they typically present to their physician soon after the episode. Gross haematuria must be differentiated from other causes of discoloured urine1. These are
