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Family Medicine: A Clinical and Applied Orientation
CS Madgaonkar
SECTION 1: BASIC PRINCIPLES
CHAPTER 1:
PHILOSOPHY OF FAMILY MEDICINE
CHAPTER 2:
SCOPE OF FAMILY MEDICINE
Introduction
Three Facets of Family Practice
Matrix of Family Practice
Proactive Role of Family Physician
Conclusion
CHAPTER 3:
FAMILY MEDICINE—THE RISING DISCIPLINE
History
Age of Specialization
Revival of Family Medicine
Future
Family Medicine—Need of the Hour
CHAPTER 4:
DEFINITIONS
General Practice
Leeuwenhorst Definition—19744
Changing Domain of General Practice (Table 4.1)
Wonca Definition—1991 (World Organization of Family Doctors)9
Olesen Definition—200010
The European Definitions—2005* (Wonca Europe Definitions—2005)11
The European Definition of the Discipline of General Practice/Family Medicine
The European Definition of the Specialty of General Practice/Family Medicine
Characteristics: The Characteristics of the Discipline of General Practice/Family Medicine are that it:
The Core Competencies of the General Practitioner/Family Doctor
Definition of General Practitioner
Definition of Family Physician
Attributes of a Family Physician
Nine Principles that Define the Discipline
Family Practice
Difference—Family Practice and General Practice
Advantages of Family Practice
Primary Care
What is primary care?15
Definition
Primary Care
Primary Care Practice
Primary Care Physician
Non-primary Care Physicians Providing Primary Care Services
Non-physician Primary Care Providers
Use of Term
How does Primary Care Differ from Other Levels of Health Care?16
Is Primary Care the Same as Ambulatory (Mobile) Care?12
Is Primary Care the Same as Managed Care?12
Role of Primary Care Provider in Common Managed Care Arrangements12
English Language Definitions20
CHAPTER 5:
THE “FAMILY” IN FAMILY MEDICINE
Focus on Family Health Care
Family—Definition
Characteristics of a Healthy Family
Characteristics of a Disturbed Family7
The Family Life Cycle and Role of Family Physician
Stages
Family Dynamics and Illness
Risk Factor Estimates
Assessment of Family Dynamics/Illness7
Family in Crisis
Caplan’s Model of Crisis Intervention
Transition Stages During a Crisis
Risk Factors for Crisis
Physician’s Role in Family Crisis7
Family-based Medical Counseling —The “Bathe” Technique18,19
Using the ‘BATHE’ Technique
Working with Families—Avoiding Pitfalls
SECTION 2: HEALTH FOR ALL
CHAPTER 6:
THE ALMA-ATA DECLARATION
Background
The Genesis of Alma-Ata
Primary Health Care Takes Center Stage
Declaration of Alma-Ata
CHAPTER 7:
PRIMARY HEALTHCARE APPROACH TO HEALTH FOR ALL
What is “Health for All”?
HFA Does Not Mean that
HFA Does Mean that
HFA—The Fundamental Principle
The Genesis of Primary Health Care2
The Concept of PHC
Phc Definition1
The PHC Approach
Ingredients of PHC (Table 7.1)
A Clinically Competent Profession
A Caring Profession
A Cost-conscious Profession
An Organized Profession
Phc Revival—Beyound Declaration
Conclusion
SECTION 3: CLINICAL APPROACH
CHAPTER 8:
THE SPECTRUM OF CLINICAL DIAGNOSIS
Introduction
Clinical Process—History and symptomatology
History
Skills in History Taking
Listen to Your Patients…and They will Tell you the Diagnosis..!
Analysis of Symptoms9,10
Limitations of Symptoms
Patient—Symptoms Variables13,14
Patient as an Individual
Clinical Process—Physical Diagnosis
Sequence in Clinical Diagnosis (Flow chart 8.1)
Diagnosis in Family Practice
The Differential Diagnosis
Changing Conceptions of Health, Disease and Diagnosis28
A Biopsychosocial Model
Conclusion
CHAPTER 9:
INVESTIGATIONS:GENERAL PRINCIPLES
Introduction
Refining Clinical Diagnosis
The Reason for the Test
Analytical Errors
Interpretation of Tests (Table 9.3)
Sensitivity
Specificity
Predictive Value
Combination of Tests
Slightly Abnormal Results
Importance of Chronological Data
Right Choice of Test
Gold Standard Tests
Who the Investigation for: Patient or Doctor?
Conclusion
SECTION 4: THE PRACTICE OF FAMILY MEDICINE
CHAPTER 10:
COMMUNICATION SKILLS
Introduction
Communication as a Core Competency
Definition
Importance of Effective Communication
Key Tasks in Communication with Patients
Key Communication Skills Needed to Perform Key Tasks7
Eliciting Patients’ Problems and Concerns
Open-ended Questions and Body Language (see below)
Eye Contact
Active Listening and Reflecting
Summarize
Giving Information
Discussing Treatment Options
Being Supportive
Communication Types
Verbal Communication (Fig. 10.1)
Where Verbal Communication is Helpful?
Non-verbal Communication (Body Language) (Fig. 10.2)
Communication with Children
Communication with Older Patients15
Barriers in Communication
Common Communication Pitfalls
Acquiring New Skills
Neurolinguistic Programming
Conclusion
CHAPTER 11:
RAPID ACCESS TO IMPROVING COMMUNICATION SKILLS
Introduction
Changing Practice Environment
Refining Communication Skills
Greeting the Patient: Rapport Building
Do Not Appear Rushed, Even if You are
Keep Conversation on Track
Listen without Interrupting
Relate with Your Eyes
Organize Your Interviews
Practice Participatory Care
Set Realistic Expectations—Provide More Information in Less Time
Going that Extra Mile
Give All Patients a Welcome Letter/Biography
Use Internet/Computers Creatively
Educate Your Staff
Follow-up
Conclusion
CHAPTER 12:
THE CONSULTATION
Introduction
Objectives for the Consultation
Patient’s Objectives
Doctor’s Objectives
Tasks in the Consultation6
Principle Tasks
Understanding Tasks
Management Tasks
The Consultation Process
Doctor-centered Method
Patient-centered Method
Pendleton, Schofield, Tate and Havelock Model13
Stewart et al Model
Byrne and Long Model
Why does the Patient Come?
Understanding the Whole Person
Find Common Ground for Action
Manage the Patient’s Disease Realistically
Interviewing Skills
The Beginning**
The Main Part of the Interview
Details of Techniques Used in Main Part of Interview
Ending the Interview — Hidden Agenda
Common Pitfalls when Interviewing Patients
Consultations as Routines, Dramas and Ceremonies
Patient Satisfaction with the Consultation
Troublesome Consultations22
Conclusion
CHAPTER 13:
THE PHYSICIAN-PATIENT RELATIONSHIP
Concepts and Changes
Types
Scope of Physician-Patient Relationship
Establish Rapport (Implied Consent)
Be Attentive and a Good Listener
Avoid Interruptions
Guide the Patient
Avoid Criticism
Avoid Emotional Reaction
Avoid Parenting your Patient
Non-judgmental
Be Gentle and Concerned when Examining the Patient
Explain the Nature of Illness
Be Clear and Discreet
Avoid Presenting Yourself as an Embodiment of Noble Profession
Confidentiality
Referrals
Relatives and Friends
Non-verbal Aspects
Closure
Ending the Physician-Patient Relationship11
Situations which may Result in a Decision to End the Physician-Patient Relationship
Situations where it is Inappropriate for a Physician to End the Physician-Patient Relationship
Conclusion
CHAPTER 14:
BALINT GROUP
Introduction
Historical Origins8
Balint Groups
Balint Training
Balint Discoveries
The Doctor as Therapy
The Diagnostic Process—Multiaxial Diagnosis*
Advice and Reassurance
Influence of the Doctor on the Diagnosis
The Doctor-Patient Relationship
Conclusion
CHAPTER 15:
DESIGNING A PATIENT-FRIENDLY PRACTICE
Introduction
Objectives to Redesign
Designing the Clinic
The Waiting Room and Reception
The Consultation Room
Staff
Greeting Patients—Checking-in and Checking-out
Incorporating New Technology
Patient Education
Patient Information
Online Appointments and Consultation
Recalls
Build a Website
Conclusion3
CHAPTER 16:
COUNSELING SKILLS
Introduction
Counseling Interventions in Primary Care
Counseling
Communication Technique
Attentive Body Posture and Languages
Appreciate Use of Silence
Using a Language Person Understands and Paraphrasing
Conveying Acceptance (being Non-judgemental)
Effective Communication Pattern
Family Physician as an Effective Counselor18
Specific Areas of Counseling
Individual Counseling
Family Counseling
Counseling Procedure
The Approach
Counseling Strategies23
Explore Patients’ Beliefs and Concerns
Inform Probable Time Duration and Outcome
Piecemeal Approach
Be Specific
Add New Behavior
The Use of Combination of Strategies
Involve Office Staff
Get Explicit Commitment
Follow-up
Refer
Conclusion
CHAPTER 17:
PATIENT-CENTERED CARE
Introduction
Why Such Broad Use?
Defining Patient-centered Care
Seven Prime Aspects of Patient-centered Care 29
Evidence Base for Patient-centered Care (PCC)
Patient’s Choice
Patient-centeredness—What Determines the Physician’s Clinical Behavior?
Patient-center Care Model
Hypothetical Case Scenario: An Adult Diabetic37
Presentation
Management: Disease-centered
Management: Patient-centered
Teaching Points
Conclusion
CHAPTER 18:
THE TEAM APPROACH
Introduction
Need for Team Concept
Personal versus Team Care
Team Training: Current Status and Assessment3
Assessing Physician Teamwork
Working with Colleagues
Communication Strategies
Be Respectful and Professional in your Interactions
Listen
Try to Understand the Other Person’s Viewpoint
Acknowledge the Other Person’s Thoughts and Feelings
Be Cooperative
Look for Shared Concerns
State your Feelings
Don’t Take Things Personally
Learn to Say, “I was Wrong”
Don’t Feel Pressured to Agree Instantly
Think About Possible Solutions Before Meeting
Think of Conflict Resolution as a Helical Process
Team Cover on Off-Duty or Leave5
Conclusion
CHAPTER 19:
LEADERSHIP
Physicians as Leaders
Changing Leadership Competency
Physicians as Better Leaders
Developing Physician Leaders
Characteristics of Leadership21
Leaders Look Forward
Leaders Define Reality
Leaders Take Initiative—Take Risks
Leaders Like Colleagues, Professionals, and People
Leaders are Self-confident
Leaders are Courageous and Decisive
Leaders Maintain Integrity
Leaders are Preservers
Leaders are Teachers
Tools for Leadership
Create Your Vision and a Mission Statement
Establish an Advisory Board
Establish Network
Become an Excellent Communicator
Group Discussion
Learn the Rules and Obey Them
Develop and Maintain a Support System
Leadership and Power
Maintain Balance in Your Life
What Physicians should do When Asked to Lead?13,14 (Table 19.3)
Asses the Task
Get to Know Your Customers
Physician-Patient Relationship
Share Your Vision
Visit with Your Team
The Limits of Spoon Feeding
Drive out Fear
Improve Yourself
Conclusion
CHAPTER 20:
DDRESSINGMEDICAL ERRORS
Introduction
New Approach—Acknowledge Mistakes
Medical Errors—Focus on Primary Care
Definition
Types of Errors
Classification
Understanding Errors in Family Practice
Why should Doctors Disclose Medical Errors
Why Doctors do not Disclose Errors (Table 20.6)
System Redesign in Family Practice
Reduce Reliance on Memory
Improve Information Access
Strive for an Error-proof System
Standardize Processes of Care
Emphasize Error Avoidance when Training Medical Staff
Apology as a System of Medical Error Disclosure
Eliminating Errors in Family Practice—Current Trends
Developing Taxonomy of Errors in Primary Care
Establish a Patient Safety Center12
Computerized Disease-specific Health System
Electronic Medical Records (EMRs)41
How to Cope with Clinical Errors 45
What Patients can Do
Ask Questions
Keep and Bring a List of All the Medicines You Take
Get the Reports of any Test or Procedure
Talk to Your Doctor About Best Hospital for Your Health Needs
Make Sure You Understand What will Happen if You Need Surgery
Conclusion
CHAPTER 21:
MEDICAL RECORDS
Introduction
Purpose of Record Keeping
Standards in MedicalRecord-keeping
Content and Style
Practical Ways of Improving Record-keeping 8 *
Weed System: Problem-oriented Medical Record (Pomr) and Soap
Progress Notes
Physician’s “plan”
Weed System and Medical Audit
Limitations of the POMR
From Soap to “Snocamp”
Medical Council of India (MCI)— Importance of Medical Records27
Medicolegal Records
Conclusion
CHAPTER 22:
THE DIFFICULT PATIENT
Introduction
Terminology and Incidence(Table 22.1)
Characterizing the Difficult Patient
Dependent Clingers
How should we Handle them?
Entitled Demanders
How should We Handle them?
Manipulative Help-rejecters
How should We Handle them?
How should We Handle them?
Who is at Fault
Problems in the Physician
Problems in the Physician-Patient Relationship
Disorders to Consider18
Strategy to Handle Difficult Patients (Table 22.3)
Acknowledge
Schedule Time
Cultivate a Sense of Partnership
Obtain the Patient’s Perspective
Review
Assess for Potential Personality Disorder
Family Involvement
Schedule Regular Follow-up Visits
Referral
Coping Skills for Physicians
Empathy
Non-judgmental Listening
Improve Communication Skills
Develop a Positive Attitude Toward Patients
Harness the Power of Self-control
Make a Conciliatory Gesture
Coping Skills for Family Physicians
The CALMER Approach26
Catalyst for Change
Alter Thoughts to Change Feelings
Listen and then Make a Diagnosis
Making an Agreement
Education and Follow-up
Reach out and Discuss your Feelings
Conclusion
CHAPTER 23:
MEDICAL PROFESSIONALISM
Introduction
Professionalism—Pitfalls
The Evolution of Professionalism
Defining Professionalism
Fundamental Ethical (Moral) Principles15
A Set of Professional Responsibilities18 (See Table 23.1)
Commitment to Professional Competence
Commitment to Honesty with Patients
Commitment to Patient Confidentiality
Commitment to Maintaining Appropriate Relations with Patients
Commitment to Improving Quality of Care
Commitment to Improving Access to Care
Commitment to a Just Distribution of Finite Resources
Commitment to Scientific Knowledge
Commitment to Maintaining Trust by Managing Conflicts of Interest
Commitment to Professional Responsibilities
Model Behaviors of Professionalism19,20
Responsibility
Maturity
Communication Skills
Respect
Unprofessional Behaviors18
Reasons for Teaching Professionalism21
The Educational Challenge
Conclusion
SECTION V: ADOLESCENT HEALTH
CHAPTER 24:
ADOLESCENT CARE
Introduction
Definition
Adolescent Consultation
Exploring Hidden Agenda
Confidentiality
History
Adolescent Communication
Communication Techniques
Physical Examination
Counseling
Goals of Counseling
Improving Existing Services— Adolescent Care Clinics (Acc)
Objectives
Guidelines for ACC
Conclusion
CHAPTER 25:
A PROBLEM ADOLESCENT
Introduction
Parenting Stress
Parenting Style and Problem Adolescent*
Behavior Problems
Adolescent Depression
Suicidal Risk
Physician’s Role*
Indications for Psychiatric Referral11
A Scheme for Fortifying the Parent-Adolescent Relationship
Guidance and Counseling to Parents
Preventive Advice to Parents and Family Members14
Conclusion
SECTION VI: GERIATRIC HEALTH
CHAPTER 26:
AGING ANDGERIATRIC CONCEPTS
Introduction
Definition
Demographic Revolution
The Role of Family Physician
Characteristics of Disease in Elderly
Nonspecific Presentation of Illness
Early Symptom Manifestations
Multiple Causes
Multiple Pathology
Delayed or No Reporting of Diseases/ Dysfunctions (Table 26.3)
Mild Disease may Result in Serious Dysfunction
Certain Patterns of Disease Presentation in Elderly
Normal Occurrence of Nonspecific Abnormalities (Table 26.5)
Dual Role of Therapy and Prevention
Conclusion
CHAPTER 27:
COMPREHENSIVE GERIATRIC ASSESSMENT
Introduction
Barriers to CGA
Medical Assessment
History Taking and its Pitfalls
Important Specific Areas
Physical Examination and its Pitfalls
Investigations23,24
Mental Status Examination
Functional Evaluation (Table 27.15)
Advance Directive28
Conclusion
CHAPTER 28:
MANAGEMENT OF COMMON GERIATRIC PROBLEMS
The “Age Wave”
Paucity of Geriatric Care
Geriatric Care and Family Physician
Atypical Symptoms (Table 28.1)
Physician’s Role
Major Manifestations of Common Geriatric Problems
Neuropsychiatric Problems
Psychological Problems and Elder Abuse
Cardiovascular Problems
Respiratory Problems
Gastrointestinal Problems (Table 28.12)
Incontenance and Urogenital Problems
Endocrine Problems
Musculoskeletal Problems
Falls and Balance Problems
Visual Impairment
Hearing Problems
Nutrition
Exercises*
Attitudes for a Successful Geriatric Practice29
Conclusion
CHAPTER 29:
PRACTICAL PRESCRIBING TO THE ELDERLY
Concerns over Aging Population
Prescribing Cascade
Polypharmacy
When should an Adr be Suspected?
Principles of Good Prescribing
Non-drug Therapy
Begin Therapy with Clear Endpoints in Mind
Treat the Disease Process Rather than Symptoms
Start Low Go Slow
Medication Debridement— Reducing Medications and Doses
Review the Drug Profile at Every Visit
Effective Communication
Medication Noncompliance in the Elderly
Measures to Enhance Compliance
Ethical Principles
Conclusion
SECTION 7: PALLIATION AND BEREAVEMENT
CHAPTER 30:
COMMUNICATINGBAD NEWS
Introduction
What is Bad News?
Why is Breaking Bad News So Difficult?
Importance of Disclosure
What Patients Value
How Should Bad News be Delivered?
Advance Preparation: Prepare Yourself to Feel Bad
Build a Therapeutic Environment/Relationship
Communicate Well: Deliver Bad News Clearly and Unequivocally
Deal with Patient and Family Reactions
Encourage and Validate Emotions: Never Destroy Hope
Communication in Specific Situations
Using the Telephone
Using a Translator
The Future
Conclusion
CHAPTER 31:
PALLIATIVE CARE: PRINCIPLES
Recognizing Dying
The Need for Palliative Care2
Special Role of the Family Physician
What is Palliative Care?
Principles of Palliative Care22 (Table 31.1)
Tasks in Palliative Care and Care of the Dying
When Death is Approaching: Diagnosing Dying20
Patient—Family Involvement: Shared Decision Making**
Identification and Management of Symptoms (Table 31.10)
Support of Family and Carers
Support after the Death
The Limits of Care at the End of Life30
Summary of Tasks for the Patients in the Dying Phase20
Physical (Comfort) Measures
Psychological Issues
Religious and Spiritual Support
Communication with Family and Family Doctor
Conspiracy of Silence
Conclusion
CHAPTER 32:
PALLIATIVE HOME CARE
Caring at Home—Some Considerations
Definition*
Home Care: Issues in Developing Countries—is There a Need?
Demoralizing Syndrome
Home—the Preferred Choice19-21
Involvement of Family Physician27
How to Get Started and Keep Going
Clinical Issues
Controlling Pain
Controlling other Symptoms
Copying with Emergencies
Drug Compliance
Patient Issues
Personal Care
Emotional Support
Spiritual Support
Nutrition
Medical Supplies and Equipment
Back up Services
Financial and Legal Aids
Respite Care
Bereavement Support
Conclusion
CHAPTER 33:
FAMILY AND THEGRIEF PROCESS
Introduction
What is Grief?
Symptoms of Grief
Features of Grief
Course of Grief5
Initial Stage
Intermediate Stage
Recovery Stage
Types of Grief Reaction
Normal Grief
Complicated (Morbid or Pathological) Grief
Risk Factors for Complicated Grief11
Family Physician as Counselor
Guidelines to Manage a Grieving Person and Family Members12
Referral
Conclusion
SECTION 8: PREVENTION AND HEALTH CARE
CHAPTER 34:
PREVENTION INFAMILY PRACTICE
The Power of Prevention
Prevention—Family Physician’s Role
Prevention—Limiting Factors
Promoting Prevention
Levels of Preventions and Screening
Primary Prevention
Secondary Prevention
Tertiary Prevention
Screening
Opportunity for Prevention
Scope for Prevention
Screening
Childhood Immunization
Health Promotion and Disease Prevention (Table 34.3)
Health Education
Patient Education
Physical Check-ups28
Conclusion
CHAPTER 35:
PREVENTIVE CARE DELIVERY: BARRIERSAND REMEDIES
Overview
Barriers to Prevention
Organization of Practice
The Patient
Religious and Cultural Factors
Absence of Symptoms and Motivation
Doctor Shopping
Anxiety About Procedures and Possible Results
Out-of-pocket Expenditure*
The Doctor
Lack of Training
Lack of Clear Guidelines for the Local Population
Lack of Confidence
Communication Skills *
Unrealistic Targets
The Payment System
Solutions to Barriers
Conclusion
Key Messages
SECTION 9: EDUCATION AND RESEARCH
CHAPTER 36:
CLINICAL AUDIT
Introduction
Definition
Why is Clinical Audit Important?2
Different Between Medical and Clinical Audit
Multiprofessional Clinical Audit in Family Practice
Difference Between Clinical Audit and Research
The Audit Cycle (Fig. 36.1)
Who should Participate?
Ethical Issues*
Steps in Clinical Audit in Any Particular General Practice**
Identifying Problems—Choosing a Topic
Agree Criteria—Consult, Involve ‘Appropriate’ Others
Setting Priorities
Set Standards for Achievement— Criteria (i.e. What should be Happening)
Agree Criteria (Data to be Collected and Analysed (i.e. What is Happening)
Identify Areas of Improvement and Setting of Standards
Pilot Audit—Make Changes, Evaluate Information
Re-pilot—Implement Changes (Repeat the Cycle when Changes are Needed)
Re-audit
Keep a Record
Confidentiality
Audit—Pitfalls
Conclusion
CHAPTER 37:
EVIDENCE-BASED MEDICINE: PRINCIPLES
A Case Scenario
Case Study Continued
Learning of Evidence-based Medicine (EBM)
What is Evidence-based Medicine?
Distinguishing Features of Ebm
Where Did Ebm Come From?
The Rationale for Ebm—the Paradigm Shift (Table 37.1)
Definition of EBM and EBP
Evidence-based Medicine (EBM)17
Evidence-based Practice (EBP)18
Steps to Practicing EBM19(Fig. 37.2)
Good
Fair
Poor
Advantage of EBM
Limitations of Ebm
Misconceptions about EBM
Conclusion
CHAPTER 38:
EVIDENCE-BASED MEDICINE: PRACTICE
Evidence-based Practice
Adherence of Ebp in General Practice/Family Medicine
Concerns about Ebm in Primary Care Practice
Restrictive Definition of ‘Evidence’ as Applicable to EBM
Concern about the Credibility of Evidence
Disparity between the “Levels of Evidence”
Guidelines could be Misused or Abused
Lack of EBM Curriculum
Barriers in General Practice
Essentials of EBM in Primary Care Practice
The Future of EBM in Primary Care
Contemporary Definition of EBP22
Conclusion
CHAPTER 39:
RESEARCH INFAMILY MEDICINE
Introduction
Background of Research in Family Medicine
What Constitutes Family/General Practice Research?
Types of Research Methodology
Quantitative Research
Cross-sectional Study
Case Control Study
Cohort Study
Randomized Controlled Trials (RCTs)
Qualitative Research
Limitations of Quantitative-Qualitative Research
Good Research in Family Practice12
Consultation with Primary Care Groups
Good Research should Take Account of the Participants
Be Aware of Competing Interests
Consider All Potential Settings
Cultural Issues
Adequate Resources
Ethical Considerations
Team Approach
Research Strategies for Family Medicine2
Aims and Objectives of Research in Family Medicine2
Methodology or Logistics of Research14 (Fig. 39.1)
What Can Family Physicians Do
Suggested Research Training and its Incentives Rewards2
Conclusion
APPENDICES:
APPENDIX 1:
Appendices INDIAN MEDICAL ASSOCIATION COLLEGE OF GENERAL PRACTITIONERS
APPENDIX 2:
REVIVAL OF FAMILY MEDICINE: A PRIMARY HEALTHCARE SPECIALTY
APPENDIX 3:
WONCA
APPENDIX 4:
Primary Health Care in India *
APPENDIX 5A:
‘ESSENTIAL’ AND ‘DESIRABLE’ CHARACTERISTICS OF A BALINT GROUP
APPENDIX 5B:
Appendix 5B Michael Balint: Biography
APPENDIX 6:
BASIC GERIATRIC HEALTH QUESTIONNAIRE
APPENDIX 7:
DISTANCE EDUCATION PROGRAM
INDEX
TOC
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