THE ROLE OF A GENERAL PRACTITIONER IN IMPROVING WOMEN’S HEALTH – By Dr. Shreen Willatgamuwa

THE ROLE OF A GENERAL PRACTITIONER IN IMPROVING WOMEN’S HEALTH 

Dr MPM Cooray Memorial lecture

 

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INTRODUCTION :

A few years after graduation I decided to pursue my career as a General Practitioner, /  given the unique accessibility a GP has to patients / at a primary care level./ As a woman GP, / I quickly realized that women & mothers very rarely gave priority to their personal & health needs. / Even though their wellbeing is of   importance for the enhancement, / functioning &/ resource mobilization of their families. / As my career progressed, / I developed special interests in the areas of Sexual & Reproductive Health and also in the / behavior of people to specific situations./  I tried to be sensitive to the needs of women I encountered professionally,/ as most women did not openly discuss issues / specially if they were related to Sexual & Reproductive Health / or about behaviors of their contacts.  / Strategies were developed to achieve my goal of improving women’s health at a primary care level.

The incorporation of certain values and principles in everyday work was a practice./ However a need was felt to acquire new skills. / I was fortunate to have had the opportunity to work at the “Therapeutic Community” Hillingdon Hospital, Uxbridge, UK with Dr Roger Freeman . An important landmark during this time was a  training workshop by Masters  & Johnson./ 35yrs ago this was quite an experience./ Until then I had not heard of surrogate therapy for sexual problems./  In 1983, I joined the  2nd DFM batch as continuing medical education is  important to a GP.

During the DFM training the importance of Family Medicine principles were stressed upon. / There was value addition to the work done with the incorporation of these principles./ This is a brief summary of the  guidelines and ethics adhered to in my practice.

Person centered Relationship based approach

Sharing decision making

Continuity of care

Confidentiality

Holistic

Advocacy

Record keeping

Health Education -Prevention/promotion

During a career spanning over 40 years work was done in several different settings as –/  Institutions, /Hospitals & at a GP consultation practice. The programs & activities were designed incorporating the special interests to suit the needs of the Institutions  &  the Community.

 Community based Primary Care

  Health promotion & prevention-

The very 1st project in the early ‘70s was at a free weekly medical clinic in an urban slum area. Services offered were curative & preventive care/ with health education. / Some household needs of the families were met by the  team after awhile./ It was learnt that the husbands & fathers / then had extra money to engage in alcohol ,/substance abuse & gambling as  a part of their responsibilities were reduced./ This project was stopped with heavy hearts after 2 yrs.

Benefits    – were  mainly to women & children as curative & preventive health care

-         Guidance & assistance for some of their daily needs

Were offered.

Learning experience

-         ‘Doing good’ in terms of offering free services can have long term negative repercussions.

-         To re-evaluate strategies during a program & change them for  best results.

FP Principle – Community based Health promotion & prevention

Kusum Sevana Community Centre

The 2nd project was in 1982 on joining the Bloemendhal Development Society, Colombo 13./  The aim of this project was to uplift living standards of the area people by conducting training programs to generate an income for adults with a special emphasis on women and to  provide a preschool & daycare facilities  for the children.

Health promotion /prevention activities –

  • Cancer Screening for Women at Kusum Sevana – The then Director/ Cancer Hospital Maharagama & Director National Cancer Control Programme  headed the screening team with the participation of the area MOH. A predesigned questionnaire/ to obtain basic information was used. Pap smears & breast examinations were done. There were 103 participants mainly from the child bearing age group. The 3 suspicious Pap smear reports  were followed up by the MOH of the area. / Follow up to assess learning as self examination of breasts etc had very poor attendance.
  • Health education discussions – The 1st talk on Puberty, Reproductive Health & Contraception was very popular. Thereafter the interest waned. Ultimately only the Rev sister & resource person were present. Subsequently for health talks a sponsoring organization was arranged to give the participants some consumables as a take away. Due to this requirement / health talks could be arranged only infrequently.

A Mother’s Union was established/.A tent with 100 chairs was given to hire out. The income generated could be taken as loans by the members at zero interest. The skills to manage the Mothers Union, guidance in administration & account keeping were taught.

Some of the skills development schemes that were conducted over the years for women & men were weaving,/ sewing, /carpentry & driving. For income generation sewing,/ making boxes for packing tea,/ work in factories or offices, / envelope pasting at home was organized

Always reputable teachers were involved. Some voluntarily & others had to be paid.

Kusum Sevana – Houses a free Pre School for children living around  Bloemendhal road. A Day Care for the children of working mothers .Five teachers & 2 nuns work at the Centre.  . A Scout Group , English & Maths classes after school for older children.   / At present there are 85 students according to the Govt. rule of teacher/student ratio. The children are provided with uniforms, school requisites & a wholesome meal  daily.

The learning experiences were many & some unbelievable. On a lighter vein for the driving program there was a lot of planning as the 3 wheel drivers selected were trained at the CTB training school. The participants had to be paid an allowance as they lost their income for half a day during the training. All 3 trainees in the 1st batch failed the test. The reason – they did not know how to read or write. We had to teach them these skills in order to pass the driving test subsequently.  Selections were done smartly for the 2nd batch. Altogether 15 drivers received their driving licenses. The Mother’s Union project of hiring the tent – had problems,/ as loans were taken only by the office bearers. The envelope pasting program done at home as unsuccessful as most of the  envelops used to get damaged due to mishaps as spillage of liquids or aaccidentally torn by a child etc. The garment factory work/office tea making   was unsuccessful as attendance unsatisfactory due to many social outings, preference for clerical jobs. This was in spite of transport provision by the employer & an allowance of Rs 6,500/- during training 20 yrs ago.

Benefits --

Health education & Cancer screening for women

Emphasis was for women with the formation of the Mothers Union

For the Women & Men skills training for income generation  Children – education & person centered care at preschool/day care

Learning experience

Adults

  • Interest to learn  short lived
  • Expects  gains immediately & in kind
  • No consistency in activities to improve self
  • Follow up to assess learning outcomes unsuccessful even though history obtained at screening  as participants lacked motivation to revisit.

FP Principle – Person centered care, Health Promotion/Prevention

At present the ongoing programs are mainly for the children. Voluntary donations & an annual raffle draw helps to fund the needs of the Centre.

Issues created by addiction to alcohol/drugs–

In the case of addiction to alcohol and drugs by men the women were empowered to pursue decision making

Mel Medura – Always / family support & counseling was available & given by the Mel Medura team & self. The women were helped / to deal with abusive relationships & they were empowered to pursue decision making pathways./ The close links with the Mel Madura team benefited clients and their contacts too.

From the inception of Mel Medura in 1984, assisting at the 6wk inpatient rehabilitation program for alcohol abuse was done./  Task as a GP was to assist with the day to day minor ill health issues as coughs, colds, fever etc. Clients requested consultations for trivia. / After 2-3 yrs the approach  was changed . Then they were taken walking to NH, OPD. The requests decreased drastically due to the walk in the hot sun & long wait at the OPD.

During the early years a success was considered only if there was 100% abstinence from alcohol. Later on an improvement in the quality of life was also considered as a success.

In the next Phase /instead of the inpatient program a /Day Care program with clients coming from home was found to be  beneficial as well.

Cyril Vas Centre – Wennapuwa  /, Mainly for in house care

Mahampitiya Hospital  – Peradeniya – provides inpatient care & follow up

Benifits –   Person centered care & / Advocay

Empower women to deal with abusive  relationships & move forward

Lessons learnt

Improvement in the  quality of life  aimed for as total abstinence   not achieved most often

Post detoxification Daycare therapy works well for some

Follow up visits were mainly due to crisis situations or ad-hoc.                   after long lapses

At least 4-5 clients benefitted each year .

FP Principle – Person centered holistic care ,Advocacy

Elderly Care Clinic –  Moratuwa, Rawathawatte Methodist Church

Elderly people over 60yrs were eligible. No segregation of men or women. For women coming with a spouse / family member was helpful.

In the late ‘80s this free clinic on a Poya day was commenced / Still continuing.  Prior to commencement the assistance of  area GPs was sought to help out by seeing one person free daily or / as possible & to assist at the clinic once in 6 to 12 months./  Clients need to be over 60 yrs./  Voluntary donations are given by parishioners for medications. / My contribution was to organize & give the technical inputs initially & as needed.

The participation of the area GPs  was not successful on a continued basis. At present there are 2  doctors who assist regularly./ Usually about 20-30 persons attend a clinic. Clients come mainly  for follow up of /DM & HT. Records are maintained. Annually a free Eye Clinic is conducted with the assistance of Help Age providing spectacles & cataract surgery.

Breast Cancer Awareness

Awareness was created among mothers of special needs children attending  the Dilma Centre in Moratuwa. This is an ongoing program annually. In 2013 85 mothers participated.

Community based Health Promotion/Prevention…

…..Was carried out by Organizing discussions & lectures regularly. Some topics discussed  were on Family Wellness, Healthy Lifestyle, Puberty  & SRH to suit the audience. Several different locations were targeted.

  • At Schools/Universities – Each child was asked to write 5 questions, several days before the program ./,These  were put into a sealed box. This helped to overcome barriers from teachers/parents. /A program focus was to answer these questions. /These programs always had a positive outcome ,over 2000 children having benefitted.
  • For older school children & in the Universities The Lectures were on puberty & SRH issues with Q & A sessions thereafter. At Colombo and Keleniya universities over 3000 students have participated. At the Med Fac. Col, for final year students – interactive sessions with role play on contraception. Have been done.
  • At Community Forums/at the Free Trade Zone in Katunayake/Biyagama/– mainly on SRH periodically for over 30 years with mainly female participants.
  • Corporate offices –lectures included Lifestyle management, Hygiene, Retirement planning along with SRH
  • For Premarital couples – Churches usually organize such programs  quarterly

-         With about  5-8 couples per program.

-         Subsequent to which many couples seek advice

 

 Lessons learnt – during Community based health promotion/prevention-

  • For success & continuity , links to State Health sector personnel for updates, advice & as resource persons. Involvement of area leaders from police, community forums , religious institutions, Grama Sevaka, MOH etc essential.
  • Initial screening data could be collected
  • Follow up  data  collection for assessment of outcomes & learning not possible due to poor attendance
  • Sustained interest poor, to improve skills or for income generation activities
  • Most often a material or curative benefit had to be  available

 

Primary care at the Work Place

At the National Carrier , Sri Lankan Airlines from 1981-2002

At the medical centre, a person centered care was made available. Several projects were also carried out within the Occupational Health requirements.

Fostering the importance of cancer screening :All staff over 35 yrs were offered cancer screening.The questionnaire used was developed by the Director Cancer Hospital Maharagama (CHM) & National Cancer Control Program / in the early 90′s .The questionnaire requested basic personal information /, family H/O CA,/ any concerns,/ previous screening etc./ Monthly, a designated section of staff ( both FM & M) were screened by a team from Maharagama & Med Cent staff. A breast examination & a Pap smear were done on all married FM participants.  As the monthly screening was ongoing there was follow up./ An awareness regarding cancer screening was fostered among the Airline staff.  

Health education – Topics relevant to the staff were done regularly.

How the Body works” in relation to Puberty/ Reproductive Health was found to be the most popular program./ Listening skills & how to respond to problematic situations was also well received.

Regular training on First Aid & Hygiene was mandatory/ for certain categories of staff to keep their work licenses current.Participation at these programs were voluntary or opportunistic for licensing purposes.

First aid information to airline cabin crew : The Book Health & Air travel was authored & made available in all aircraft 1st Aid kits./ Information on First Aid,/ other relevant topics,/ how to deal with passenger requirements /emergencies on flights/ were included in this book. A certificate course was conducted regularly by St John’s Ambulance or by other reputed institutes.

Contributory Hospitalization scheme for staff & families – This scheme was  helpful & cost effective to staff as they were able to obtain the best care available/ with guidance from the early ‘80s. /Eg. Of a benefit – A maternity benefit of Rs 500/- was given for the birth of the 1st  two children. In the early ‘80s  Rs 500 was sufficient for the basic requirements of the mother & child as toiletries, mackintosh, net etc. / & for taxi fare / to & from hospital.

Counselling -was made readily available to staff

Links with State Health Sector –Projects done fostered closer links to the respective state sector facilities. & personnel. The links were beneficial to both parties. Staff benefitted during hospitalizations

-         National Blood Bank –  An annual Blood donation campaign was held on 1st Sept for the Airline anniversary. This was a popular program where other airport staff  also participated. /This link was beneficial to the Blood Bank & to UL staff. Specially during the terror attacks the Airline was able to  help out with emergency blood donation campaigns at immediate notice

-         Wesak Shramadana – Annually held at the DMH, LRH or NH, & was a much looked forward to event. The technical teams attended to needs of the chosen ward for a couple of weeks ahead of the due date. Cleaning, painting etc was done on the appointed date.

This event fostered a family & team spirit with links to the hospitals.

-         Family Health Bureau – Always assisted in issues related to Women & Children. Resource persons for HE of staff & CME for the Med. Cent. Staff was regularly done.

-         NCCP –  With cancer prevention programs & updates

Lessons learnt – A meaningful Family practice is possible at a work place

-         Although the cancer screening program started off as a screening for detection of lesions the main achievement was the fostering of an awareness to screening. This was probably due to the young ages of the participants.

-         To maximize on opportunities to further health care & benefits in the environment of a commercial Airline.

FM PRINCIPLE : Person centered care, Continuity of care, Confidentiality,

                             Record keeping, Health education

 At Family Planning Association-  2007-2010

Commencing a Sexual Health Clinic in 2008

This clinic included a multidisciplinary team including Psychiatrist Dr Kapila             Ranasinghe (KR) who has special training in sexual health headed the team.

Many clients with Gender Identity Dysphoria (transgender) & with different sexual orientations obtained advice. /Information about the team/services was mostly by word of mouth.

The team has close links to other organizations that address these issues. These links work well for the clients.. The organizations are  Equal Ground,/ Heart to Heart / DAST(Diversity & Solidarity Trust),/ Companions on a Journey(Non functioning now) / Women’s Support Group, etc.

The guidelines adhered to when assisting  Transgender  clients :

Are found in DSM IV , DSM V and Good practice Guidelines of the Royal         College   of Psychiatrists London Oct 2013

A format was developed for recording history & follow-up visits of clients.

Rosenberg Self-Esteem scale is given to clients periodically.

The clients are seen at the NHSL clinic of Dr KR or at my clinic to date.

Observations – Clinic attendance by clients  ad-hoc.

-         Contact is sometimes over the phone once client is familiar

-         On peer advice or from internet many self medicate hormones

-         Most often information given to us after surgery in SL / eg mastectomy & hysterectomy. For reconstructive surgery clients proceed to Bangkok or India/ once again secretively.

-         Information given to doctors by clients may be limited/unreliable at times

-         Family counseling sought by quite a few clients. Family members grateful as they feel lost & disturbed regarding the behavior of their loved ones. Some clients are professionals, some others married with children.( some feel if they marry, have children they thoughts to change will go away)

-         Quite a few clients reluctant to link with others with similar issues

-         At present 75  clients  attend clinic

Guidelines for clients

–   Getting a Psychiatric assessment

-          social & family stability is encouraged with follow up visits

-         Occupation for a regular income needed. Options/strategies discussed

-         Advice to avoid risky behaviors given

-         Live the chosen life / ie preferred gender for 2yrs prior to decision making & therapy

-         Thereafter according to laid down guidelines in DSM V etc

Assistance given for documents needed for security, travel & administrative needs.

All  decisions taken solely by the client at their own initiation.

Our team is available for guidance ,to lend a listening ear  to the client &  family .

FP Principles -  Advocacy, Confidentiality,  Counselling

 

National Institute of Mental Health – (NIMH- Angoda)

To provide SRH services to inmates & staff.

This project was to evaluate the actual needs of inmates, educate staff & find ways to improve service provision to inmates without compromising their self esteem.

Approximately 1000-1200 inmates at NIMH, Angoda/ & 754 at Mulleriya./ There was a dedicated team of 900 staff consisting of doctors, nurses, attendants & support staff./ Like all human beings / these inmates have many issues related to SRH needs such as fertility, contraception, sexual desires, deviations, reproductive tract infections & STI./ Due to their unstable mind they can be subjected to physical & sexual abuse./ In addition they can act in a provocative manner.

It does not occur to most people that mentally unstable people also   have /SRH needs & problems./ Thus SRH issues had not been considered as a part of their day to day life./ Similarly majority of staff have also not considered the SRH needs of the patients they care for.

Most patients who benefitted were women. Many patients do not complain of a gyn problems. When a gyn problem is suspected a referral is made to DMH, CSWH or NH,. / 5 staff needed for a single clinic visit by a patient./ Often patient gets agitated & the visit has to be cancelled./ As these clinics are busy, the staff over worked they may not be sensitive to  needs of psychiatric patients/ .In addition there may be long waiting times causing restlessness & difficulty to manage these patients

Phase 1-  To educate staff at NIMH on SRH, STI & SRH during various stages of

psychiatric illnesses.

-To educate the care givers, parents & guardians on SRH needs of inmates

Medical officers from the FHB, NH,STD clinic & NIMH assisted with the HE.

PHASE 2-  Conducting weekly clinics at NIMH on a Wed from 9am-12 noon from 2nd July 2008./ Situational analysis done by data collection of services provided. Links to MRI,/ STI clinic NH,/ FHB,/ DMH/,CSWH in order to provide user friendly cost effective services./Non urgent USS done weekly at FPA.

Observations from 2nd July -15th Oct-

All patients needing Ix / for STI evaluated./ Samples taken for HVS, VDRL, HIV sent to MRI. / Pap smears done at FPA

Contraceptive method administration needed recommendation by 2 doctors from NIMH & a family member. eg Usually IUD or DP suggested due to long term effectiveness.

Gyn USS done at FPA clinic by a Radiologist.

Similar services provided for staff at NIMH & Mulleriyawa.

FPA provided the medical services, Pap smears, USS & transport free of charge.

A clinic space was allocated at NIMH with a dedicated nurse.

Clinic ongoing to date. App. 20 – 30 clients seen weekly.

FP Principles – Person centered holistic care, Advocacy

HIV /AIDS service

HE  services to Internal Migrants in the Industrial Promotion Zones of Katunayake, Biyagama & Koggala who were mainly women.

At FPA clinic   consultations , counseling & referrals  to NH,STD clinic or IDH

Links with  HIV +ve  Women Activists who are well known Nationally & internationally /“Lanka +” &/ “Positive Women’s Network SL /,Positive Hope Alliance” & others fostered

Health Education talks –such as Healthy Lifestyle diet, hygiene etc for +ve  persons done

Social support activities  periodically.

FP Principle – Advocacy, person centered care

New contraceptive FOR WOMEN – Jadelle  -

After training / awareness &   lecture  demonstrations in collaboration with  SLCOG in the Western province ,NW , N  & E, for doctors, Nurses, Paramedical staff & clients .( State sector used Implonon at that time)

FP Principle – Health Education, Person centered approach

LISA – “ Life Saving” This was a project  funded by the UNFPA.  for Internally Displaced Women and children,in the North & East.

Support was given for the Government programs conducted by MOH offices for Women & Children through the

FPA  had Field offices in Trincomalee, Batticolao ,. Vavuniya, Chettikulam, Mannar & Amparai. Through these outlets the. At the end of the war monthly Hygiene packs, Maternity packs for pregnant women( given at 28wks) were prepared & handed over to the State officials for distribution. This task was handed over to the State Trading Corp after a short while. FPA had 2 Mobile Clinic vehicles with water, electricity & examination facilities. Later 2 more vehicles were constructed.  Field testing strips kits for blood sugar, Hb, etc was available.  Subsequently clinics were constructed & Furniture provided for each Zone ( camps 0 to 5) according to specifications by FHB. .

HE programs on SRH were conducted regularly by FPA trainers for the  internally displaced women & Youth.

FPA trained a team of volunteers who helped daily in numerous ways in the N& E.

FP Principle – Person centered Holistic care, Health education

Books / Research /  Health  Education(HE)

Person centered needs to mainly empower women was done through books , research projects & lectures,  . A variety of materials & information techniques catered to different needs of clients.

 Books – Were for HE giving a basic idea on how to move forward.

              -  Contraception – “For a Happy Life”

              – Subfertility – “The joy of a Baby”

                    - Unplanned Pregnancy – “ Plan your Life”

                    -“Unwanted/Unplanned Pregnancies & their Aftermath”

for GPs a chapter on case scenarios in order to be sensitive to the unspoken needs of the client.

“Reducing the burden of Unsafe Abortion’a Situational Analysis in SL” – co-author

FIGO & IPPF invited SLCOG & FPA to participate in a global initiative to address issues of unsafe abortion. An in-depth literature search was conducted. Based on the findings a plan of action was developed to reduce the burden of unsafe abortion. Although the SLn / law is restrictive on abortion an estimated 125,000 – 175,000 induced abortions are performed annually according to available literature. / Surprisingly most studies concluded that more than 90%of them were married women contrary to common belief.

It is interesting to note the national / CRP rate is. high

Some of the specific interventions suggested were an increased information on modern contraceptive methods,/ use of ECP,/ SRH education in schools & higher education institutes etc.

In all of these activities women’s health was advanced both physically & psychologically .eg in an unplanned/unwanted pregnancy or sub fertility the woman suffers silently. In  my experience most women take the blame.eg even when the problem is/ with the subfertile husband.

Research done -  

 Sub fertility & sexual problems -2007

A Retrospective Analytical study was done of couples attending a sub fertility clinic at FPA to determine whether sexual problems(SP) were contributory to delay in conception.

To find out the

  • common causes for delayed conception ,
  • commonly encountered SPs
  • to determine whether sexual problems make a significant contribution to delay in conception.

983 couples presented to the sub fertility clinic from Jan 2004 –Dec 2006

Data in clinic records obtained by qualified medical officers & trained nurses

Exclusion criteria

  • Couples who did not come for follow up & investigations.
  • Couples who complained of SP but/ had a coital frequency of 2 per week or more with penetrative sexual intercourse & ejaculation.
  • Those who complained of premature ejaculation but records insufficient to ascertain whether ejaculation occurred prior to or after penile  penetration.

Causes for delay in conception-

Male factor              – 206 (20.96%)

Female factors        – 206 (20.96%)

-         PCOD – 61(6.2%)

-         Other ovarian factors 62(6.3%)mainly endometriosis

-         Tubal factors 69(7.04%)including changes due to endomet

-         Uterine factors 14(1.42%)

Combined factors          – 89(9.05%)

Idiopathic sub fertility   – 441(44.86%)

Sexual problems             - 41(4.17%)

Commonly encountered sexual problems

-Number of couples with SP – 41

-7 couples had 2 sexual problems. 7 were taken separately resulting in 48 cases

-Erectile dysfunction           – 25 (52.08%)

-Vaginismus / Dysparunia – 17 (35.42%)

-Other problems                   – 6 (12.5)

- Number of couples with SPs only -26

- Number of couples with SPs & other causes – 15

- Number of couples who had no penetrative sexual intercourse – 11

There is a statistically significant association between SP & delay in conception

Therefore it is important to explore sexual behaviors before investigating for sub fertility

Discussing sexual behaviours with couples will help them to disclose their unmet needs regarding SPs.

 “ Postinor” use – In 2009 a descriptive study was done at FPA on factors associated with / Emergency Contraception Pill( ECP) use among Sri Lankans who use / modern communication technologies .

160 randomly selected clients of “Happy Life” SRH information centre who have used ECP & contacted us over phone or internet. Data gathered after taking verbal consent

66.9% FMs , 58.8% married, 48.8% from Colombo district,

Age groups 20-24yrs(35.6%) & 25-29yrs(26.6%),notable that 15-19yrs(10%)

96.3% had taken ECP within 72hrs of unprotected Sexual Intercourse(SI).

6.6% used ECP more than 6 times within past 3mnths

85 % married participants not on a regular contraceptive method

  • Identified only 3 (3.2%) ECP failures
  • Most participants were FMs from sexually active age group. /
  • Age group 15-19yrs also sexually active, they need guidance for their sexual  needs./
  • Minimal contact from other living areas need identification of reason./ Participants had sufficient knowledge on correct timing but not on frequency of use , which may have contributed to failures.
  • Lack of taking a regular CM is a problem that needs further assessment to provide solutions.

Pap Smears - A study was done in 2008 to determine the relationship between contraceptive method (CM) used & Pap smear(PS) report.

Limitations- Data collected was 2ry data, some inconsistencies noted. Slight differences noted in PS reporting done by 2 consultant pathologists.

1219 PS reports collected from1.1.2006 to1.5.2008.

Client age, parity, current CM & district of residence were considered.

Mean age 42-88yrs. Many between 35-50yrs

Acceptable reports – 1196

Normal smears -54%  ; Abnormal smears – 46%

CM non users 25%

Most popular CM – IUD

55% had two children  ;  Colombo district clients 66.7%

PS reports differ significantly with age (p- 0.000) with atrophic smears as main change for >50yrs

Statistical difference seen between Group 1 using IUD, DP, OCP, Condom  &

Group  2 all other methods(Traditional, LRT, Vasectomy, no method, menopause).

Study found – CM does not make a difference to the PS report (p-0.66)

-PS reports were not seen to change with number of children (p-0.39)

-No statistical difference seen among the different modern CM used

-Cervix influenced hormonally or physically

- No known influence on Cervix due to CM that was used. This could be due to the small sample size or due to changes noted for all  CMs used.

- Changes with age may be due to early initiation of SI or number of  sexual exposures which usually > with age & may < with  menopause

Thick condoms – A  study was done to evaluate the suitability & need for thick condoms  by “Companions on a Journey” . A questionnaire was filled by their members &  analyzed.

Vaginal Practices(VP) in SL – 1st Oct 2008 – 31st Aug 2009

No documented evidence in SL regarding vaginal practices although clinicians observe these practices during consultations & examinations. By identifying these practices, awareness can be created among health care workers & general population if the practices are harmful to the female, spouse or both.

Study was to evaluate the VPs in Sri Lankan FMs. Identify VPs among Urban, semi urban & rural women & observe differences due to  living location. Identify VPs relevant to age, stage in life, other reasons & products used.

All females over 18yrs & willing to participate would be included to fill the structured questionnaire

Ethical clearance obtained from Ethical review committee Fac.Med,Uni of CMB. For FM doctors & care givers to explain & hand over the questionnaires.

Health Education – on SRH and Contraception

Given regularly to-

-          Post Grad teaching- Dip in RH, DFM online, MCGP

-         General public

How – Specific needs of clients attended to as contraception, sexual issues, cancer screening, sub fertility  at the clinic & in the community.

-         Health education was for different requirements either personal or academic needs

-         Person centered care given at Sexual Health Clinic & NIMH

-         Proper planning & awareness of stakeholders contributed to the success of programs .

 

FP Principles : Person centered approach, Advocacy, Health Education, Confidentiality,  Record keeping.

 

At Hemas Hospital WattalaThe Family Health clinic contributed to the needs of the hospital with a special emphasis on the unmet/little thought of needs in women.

Pap Smears -  1228 Pap smears were done from May 2007 to April 2014. The same Pathologist reported on all the samples. These clients were between 35 -65 yrs , from urban areas for routine screening. No adverse results were detected

Health Education – Promotion/Prevention Programs

  • Lectures & Discussions- done for-Corporate clients/Companies ,Community,  Antenatal clients, Staff
  • Articles & discussions in  print or electronic media

Topics – RH/Contraception ,  Healthy Lifestyle , Retirement planning etc

Nirogi Paada program – participation gave the current updates on Diabetic foot care management.

Introduction of Alcoholics Annonymous to a Private HospitalMeetings were started in September 2013 on Sundays at 6.30 pm. The hospital provided an area for the meeting which is conducted by the members. This meeting is progressing well as clients find the environment secure & the numbers have doubled. This was the 1st AA meeting in a Private Hospital. AA meetings are held in many Govt hospital eg – Negombo, Minuwangoda etc.This benefits women,as they find a hospital environment secure to come for discussions/help.

Counselling – For clients & staff

GP Hospital Link  was built up – Mainly the personal relationships with GPs & Consultants, especially those in the vicinity of the hospital. These links fostered  a  mutually beneficial referral systems.

Known GPs would refer patients for para-medical services & hospitalizations. Coordination, information & referral back to them fostered this system.

Difficulties encountered -

a)    Unknown GPs were uncomfortable to link with the hospital even with a dedicated coordinator

b)   GPs unable to come for regular time slots to hospital – to link with para- medical  services

c)    Admissions to HHW only under a consultant

d)  GPs not familiar with regular visits to inpatients at hospital & about their charges

e)   With GP visits the hospital bill of patient would increase

 

FP Principles – Hospital & community based health promotion & prevention, Health Education, Person centered holistic care, Continuity of care, Record keeping, Confidentiality, Advocacy

How – Contact with clients own GPs giving a personalized care.               Para medical services not found at GP clinics coordinated            Hospitalizations GPs clients coordinated for them with updates

Similarly for sexual issues,

HIV & Transgender clients personalized services

Counselling & Continuity of care

Some situations addressed throughout- mainly woman centered

Contraception –sensitivity to religious/cultural beliefs

TOP – How to respond in relation to the law of SL

Work related comments-

( As, I always worked for an institution/hospital there were advantages as a fixed income , fixed work times, leave entitlements etc. which definitely helped me along the way)

CONCLUSIONS :

A special interest can be pursued and modified to suit the work environment.

Continuing medical education is important for best practices.

Application of Family Medicine principles give value addition & protection to the patient and the GP.

Sensitivity to the social & religious background & the law of the land must be kept in mind when dealing with clients.

Links to the State Health sector & Community leaders helpful.

I am happy to share with all of you my message that whatever the working environment  as a GP one is able to pursue  special interests in order to assist  patients with a special emphasis on the women.

In my experience and as per my observation in this ever changing world as Gale Holtz Golden says ” YESTERDAYS PERVERSION IS TODAYS DEVIATION AND TOMORROWS VARIATION ”

I need to thank the different team members who helped me in all of my work .It is not possible to mention all their names. Today I miss my mentor & guide Dr Surendra Ramachandran, who was always  present during my career. My sincere appreciation & thank you to the guidance given by Prof Antoinette Perera, Dr Janaka Ramanayake & my friend Dr Eugene Corea whose life I disrupted many, many times during the past 3 months. Lastly to my daughter Samantha for the all the hard work she did for this oration including polishing up my writing skills & language.

Thank you Mr. President for those kind words of introduction.

Mr President,/Chief Guest Prof Mohan de Silva,/ Guest of Houner Dr Suresh Kumar,/ Immediate past President,/ distinguished past Presidents,/ Members of the Council of the College of General Practitioners,/ Members & Associate Members of the College , / Family members of the late Dr MPM Cooray,/ Ladies & Gentlemen.

Thank you Mr. President & the members of the Council for selecting me to deliver the College Oration./ I am honoured by the selection & I hope my oration will be a tribute to the late Dr MPM Cooray.

Today,/ we commemorate the life & work of Dr Manna /marakkalage Philip Micheal Cooray

In every  country ,/each generation produces  few men,/ distinguished from their fellowmen; by their intellectual capacity,/ achievements/ concern & consideration for fellowmen./ Such a man was Dr MPM Cooray.

Like many other luminaries of Sri Lanka / he hailed from the south / & had his 2ry education at St John’s College , Panadura & St Joseph’s College , CMB. / He joined the then Ceylon Medical College in 1929 / & at the end of the 2nd year / left for UK.  He graduated with MBBS from the University of London / &  later obtained his MRCS & /  LRCP.

On his return to Ceylon / he was appointed Physician to the Kegalle Hospital / & later to Badulla Hospital./ This was followed by many years of service in the Health services/ including a period as the Physician in charge at the Fever Hospital , Angoda.

His special interests were in the History of Medicine./ & in Infectious Diseases. In 1954 he handled the 1st & only Small pox epidemic in Sri Lanka.

The late Dr Cooray / was elected President of the Ceylon Medical Association in 1968, / presently known as the Sri Lanka Medical  Association. In 1972, / he along with 18 others / formed the College of General Practitioners./ where he was elected as the /Founder President. He was also elected the President of the Independent Medical Practitioners Association / which played a significant role / in the founding of the College of General Practitioners. / He / continued to serve the Council of the College / until his time of death in November 1990.

He was a Past President of the Catholic Doctors Guild & a very active member throughout his life / during which he contributed greatly to the Guild. The other oration given in his memory is at the Catholic Doctors Guild. This Dr M P M Cooray Memorial oration / has created history in the annals of medicine in Sri Lanka / being the only (i)  /  eponymus memorial lecture organized by a religious / professional body, / one of the principal offices of which / like that of history, in the words of Tacitus, / is to prevent virtuous actions being forgotten.

The late Dr MPM Cooray was married to the late Esther de Soyza grand daughter of the late Sir Charles Henry de Soyza the founder of the De Soyza Maternity Hospital Sri Lanka. They had 3 sons & 5 daughters./ His eldest son Dr Hilarian Cooray & his wife Dr Manel Cooray have been close associates of mine. Hilary is a well known Dental Surgeon in CMB. 3 of his children & one of his sisters are / doctors. / Certainly, the late Dr & Mrs Cooray would have been very happy & proud grandparents / if they were among us today / having accomplished their goals in life, / even for generations to come.

( Mark Twain once said , I quote, “ Praise is well, ? compliment is well, / but affection & trust is the last & final & most precious award , that any man can win, whether by character or achievement “ I unquote. All these are possed by Dr MPM Cooray. )

As a tribute to the late Dr MPM Cooray, a man of great wisdom & learning my talk  this evening is based on some topics of  interest that come within the purview of issues faced by General Practioners in the 21st century. The title of my oration being – “ A General Practice approach to Health needs of Women” / a way forward.

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