Selective Lecture Notes “Caring Doctor and Long Term Illnesses”


Lecture 1 (Carer Stress and Long Term Illnesses)


“Carer” includes the following groups of people:


1.     Medical providers such as doctors, nurses, allied health professionals such as physical therapists etc.

2.     Hired help

3.     Family members (spouse, parent, relative – especially daughters)

4.     Social service agencies


“Stress” can be defined as feelings of psychological discomfort, tension, anxiety


Arises from – external pressure e.g. “stressful life event” (including sudden changes in the health of a family member) or a stressful situation.


Feelings of stress are affected by the perception of the person and the coping ability of the person. Person A may find situation X mildly stressful while Person B may find it very stressful.


Prolonged stress can lead to illness or trigger chronic disorder e.g. asthma episode.


Reactions to Stress include: irritation, frustration, anger, feeling helpless, depression, rejection, avoidance, somatization (psychosomatic illness)


Stress for the Doctor

1.     Stress of breaking bad news

2.     Stress in handling patient’s stages of adjustment

3.     Stress in managing patient’s behaviour towards you (the “Difficult Patient”) e.g. nonadherence, self-destructive acts, dependency and manipulation, hostility


Nature of Doctor-Patient Interaction is affected by:

1.     Age of the patient

2.     Social class/culture of the patient – level of education, economic resources, family support or lack of it, health beliefs

3.     The health condition e.g. Down’s syndrome, diabetes, hypertension, renal failure, Alzheimer’s disease, serious psychiatric illness etc.

4.     Handling the dying patient (see “On Death and Dying” by Elisabeth Kubler-Ross)

5.     Personality of the patient e.g. patients who have problems with authority, dependent personalities, domineering personalities


Factitious disorders à self-induced symptoms in order to get attention from the doctor e.g. self-mutilation, falsely-reported symptoms, laxative abuse.


Lecture 2 (Patient and Family Stress in Long Term Illnesses)


Impairment, Disability and Handicap


Impairment: loss or abnormality of bodily function


Disability: restriction in performance of normal activities (ADL: “activities of daily living” such as getting out of bed, going to the toilet, bathing, dressing, feeding, moving about, etc)


Handicap: resulting disadvantages that arise (especially those of a social or economic nature) e.g. loss of social roles, stigma and discrimination, unemployment


Patient and Family Stress


1.     Patient needs to adjust and cope

2.     Financial stress – loss of job, cannot find a good job, higher medical expenses, may require frequent hospitalizations, family member may need to work part-time or stop working to look after the sick relative

3.     Possible stigma and discrimination

4.     Embarassment/shame felt by the patient and family members

5.     Social isolation (difficult to move around)

6.     Role changes in the family – tension may result

7.     Changed physical appearance

8.     Sexuality e.g. paraplegics, impotence

9.     Maintenance of self-esteem

10. Lifestyle changes, medications, pain management

11. Worries about the future e.g. will I marry? Can I have children? Who will take care of me after my parents die?

What can the Caring Doctor Do?


Help the patient to cope

Help the family to cope


So that: Life is as “normal” as possible

             Quality of life is as “good” as possible


1.     Help the patient to accept his or her condition

2.     Educate the patient and relatives

3.     Help to lower the medical expenses e.g. prescribe generic drugs, charge less or even free care!

4.     Refer to appropriate social service agencies for follow-up care

5.     Empathy (and be available)


Lecture 3 (Introduction to Field Research)


Research: systematic investigation of physical or social phenomena that interest us


Why do research? Try to “explain” the phenomenon e.g. What is the pathogen for recent outbreaks in Negri Sembilan and Perak? What is the mode of transmission?


To use new knowledge to predict and control events e.g. stop the epidemic, prevent it from occurring again


Basic Research versus Applied Research: Basic research is conducted with no immediate applications in mind. It is often more theoretical in nature. Applied research is problem-oriented research. Has immediate applications in mind.


Research Methods


1.     Experimental e.g. clinical trials of drugs

2.     Surveys – Interviews and Questionnaires

3.     Observation – Direct Observation and Participant Observation

4.     Documentary sources – published statistics, historical archives



Doing Field Research


Observation #

Participant Observation

Unstructured Interviews

Structured Interviews #

Questionnaires #


# Best methods in your case


All research methods have strengths and weaknesses

Treat research subjects with respect

Maintain confidentiality of data

Respect their privacy and rights


Challenges of Observation Research

1.     “Observer effect”

2.     Time-consuming

3.     Need to gain access and trust

4.     One can become over-involved and be biased in recording data


Challenges of Surveys

1.     People may refuse to cooperate

2.     People may lie when answering questions

3.     Wording can affect the response

4.     Sensitive questions may offend

5.     Cannot ask probing questions


Process of Field Research


1.     Specify your research question (goals)

2.     Review the literature

3.     Design the study

4.     Collect data

5.     Analyse data

6.     Write the report


The Report


1.     Abstract (unnecessary in your case)

2.     Introduction

3.     Methods used

4.     Results

5.     Discussion

6.     Bibliography and References (AVOID PLAGIARISM!)


Choose a reference format and follow it strictly e.g. Medical Journal of Malaysia format


Soter NA. Cold uticaria. New England J Medicine 1976;294: 687-90.


Osler, AG. Complement: Mechanisms and Functions. Englewood Cliffs: Prentice-Hall, 1976.


Lecture 4 (Paying for Long-Term Care)


Rising healthcare costs: major problem in all industrialized countries. Emerging problem in Malaysia.




1.     Technology – expensive drugs, expensive technology

2.     Ageing population

3.     Epidemiological transition – disease pattern changes

4.     Rising expectations – people expect higher standards

5.     Medicalisation of social problems

6.     Market failure – supplier-induced demand


Basic “Health Economics” concepts

1.     Scarce resources and choice

2.     Opportunity costs e.g. if the Government builds a big hospital in the city, less money is available for immunization programmes, antenatal care etc.

3.     Externalities e.g. if more of my neighbours get immunized, I am less likely to get disease X

4.     Equity in access to healthcare – need? Ability to pay? Maldistribution of resources (urban-rural, male-female?)

5.     Rationality – goal-oriented behaviour e.g the Nipah Virus outbreak. What is the best way to tackle it? List the goal(s), Identify strategies to reach the goal(s), Choose the most cost-effective strategy

6.     Efficiency – “more bang for the buck”. Technical efficiency – maximize benefits at lowest cost e.g. immunize against polio rather than treat the disease. Prescribe generic drugs in place of expensive branded drugs. Allocative efficiency – allocate resources to get maximum returns e.g. spend more on prevention or on high tech medicine? Spend more on health or more on a better water supply, better sanitation system, pollution control, nutrition programmes, regulation of factories?


Paying for Long Term Care


Private Sector

1.     Self-pay: savings, borrowings

2.     Relatives

3.     Employers

4.     Charity, NGOs and PVOs

5.     Health Insurance


Public Sector

1.     National Health Service – financed by taxes

2.     Nation Health Insurance – financed by individual contribution and employer contribution


Variants: Singapore has Medisave, Medishield and Medifund. Medisave is a system of forced savings for health expenses.

USA: Medicaid and Medicare. Managed Care and market competition.