About prevention : the quaternary prevention

1
About prevention the quaternary prevention
15th Wonca Europe Conference 32nd SSMG/SGAM
Congress 1619 September 2009, Basel,
Switzerland The Fascination of
Complexity Dealing with Individuals in a Field of
Uncertainty

• Marc Jamoulle,
• Family doctor researcher
• Members of the Wonca international Classification
  Committee
• Centre académique de médecine générale, UCL,
  Brussels, Belgium

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Let us discuss just a litle bit the concept of
clinical prevention and time line in family
practice

• A determined Process
• About a vulnerable Problem
• In due time

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1958
Chronological approach, provider centered
Diagnose Early treatment
Health promotion
Rehabilitation
Specific protection
Disability limitation
Primaire
Secondaire
Tertiaire
PREVENTIVE MEDICINE FOR THE DOCTOR IN HIS
COMMUNITY. By Hugh R. Leavell and E. Gurney
Clark. (With 19 Contributors.) New York The
Blakiston Division, McGraw-Hill Book Co., 1958.
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Chronological approach, provider centered
A process about a problem along the time line
Secondary
Primary
Before
After
Onset of the problem
Ex secondary prevention of relapse by
Aspirin after acute coronary heart disease
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Cognitive and Chronological approach, patient
centered
Doctors views
Could be very different from
Patients views
6
Mixing patients and doctors views in primary
care
Onset of the problem
You are I am
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Mixing patients and doctors views in primary
care
Onset of the problem
You are not Im not
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Mixing patients and doctors views in primary
care
Onset of the problem
You are Im not
9
Mixing patients and doctors views in primary
care
Onset of the problem
You are not I am
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Let us see those concepts in a different way

• Crossing doctor and patients views Time line is
  no more the central issue
• Between disease and illness
• Between science and conscience
• Between patient and doctor

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a
_

Doctor
Disease
_
Patient
Illnes
Time line

O
12
_

Doctor
Disease
_
Patient
Illnes
I
I
II

III
IV
III
Crossing patient and doctor thoughts open four
interpretation fields
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13
_

Doctor
Disease
Patient feel him/herself well Doctor can find
nothing wrong
_
Patient
Illnes
I
I
Primary prevention

III
Ex Immunization or prevention of falls
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_

Doctor
Disease
Patient feel him/herself well Doctor look for
disease. The doctor bets on the disease.
_
Patient
Illnes
I
II
Secondary prevention

III
Ex screening Cervix/ Breast/ Scoliosis
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_

Doctor
Disease
Patient feel him/herself sick Doctor agrees and
looks for complications
_
Patient
Illnes
I
II
Tertiary prevention

III
Ex retinopathy prevention in diabetic
patients Aspirin in post infarctus
III
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_

Doctor
Disease
We got three
_
Patient
Primary prevention
Secondary prevention
Illnes
I
I
II
Tertiary prevention

III
III
Patient feel sick Doctor can find nothing wrong
What about the remaining one ?
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_

Doctor
Disease
_
The anxiety of the patient meets this one of the
doctor You have nothing - Its in your head
-Hypochondria Hysteria - Munchausen - Non
disease disease - Medically unexplained symptoms
-Worried well - Somatoform disorder
-Somatization - Somatic fixation - Abnormal
illness behaviour - Non disease syndrome
Functional somatic syndromes Its the field
of chronic fatigue syndrome but also of not yet
diagnosed Multiple Sclerosis
Patient
Illnes

IV
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Let us have a look back at the definitions

• As published in the
• Wonca Dictionary of General/Family Practice

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I Primary prevention
Action taken to avoid or remove the cause of a
health problem in an individual or a population
before it arises. Includes health promotion and
specific protection (e.g. immunization)
I
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IIsecondary prevention
Action taken to detect a health problem at an
early stage in an individual or a population,
thereby facilitating cure, or reducing or
preventing it spreading or its long-term effects
(e.g. screening, case finding and early
diagnosis)
II
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IIItertiary prevention
Action taken to reduce the chronic effects of a
health problem in an individual or a population
by minimizing the functional impairment
consequent to the acute or chronic health problem
(e.g. prevent complications of diabetes).
Includes rehabilitation
III
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The field four is a hole where patients fall due
to miscommunication, misunderstanding, anxiogenic
health education, unstudied screening campaign,
bad public health program, personal fear of the
patient, health belief, anxiety of the provider,
defensive medicine, uncontrolled technology or
specialist based care, unstudied complementary
medicine..
_

Doctor
Disease
_
Patient
Primary prevention
Secondary prevention
Illnes
I
I
II
Tertiary prevention

III
III
IV
Ex Unfit health prevention campaign
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The field four is a hole where patients fall due
to miscommunication, misunderstanding, anxiogenic
health education, unstudied screening campaign,
bad public health program, personal fear of the
patient, health belief, anxiety of the provider,
defensive medicine, uncontrolled technology or
specialist based care, unstudied complementary
medicine..
_

Doctor
Disease
_
Patient
Primary prevention
Secondary prevention
Illnes
I
I
II
Tertiary prevention

III
III
IV
Ex non targeted breast campaign
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The field four is a hole where patients fall due
to miscommunication, misunderstanding, anxiogenic
health education, unstudied screening campaign,
bad public health program, personal fear of the
patient, health belief, anxiety of the provider,
defensive medicine, uncontrolled technology or
specialist based care, unstudied complementary
medicine..
_

Doctor
Disease
_
Patient
Primary prevention
Secondary prevention
Illnes
I
I
II
Tertiary prevention

III
III
IV
Ex 3 mm angioma in the liver
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_

Doctor
Disease
_
Patient
Illnes
I
Quaternary prevention

III
IV
Listen to the patient Control medicine
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IVquaternary prevention
Action taken to identify patient at risk of
overmedicalisation, to protect him from new
medical invasion, and to suggest to him
interventions, which are ethically acceptable
IV
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IIsecondary prevention
I Primary prevention
Action taken to detect a health problem at an
early stage in an individual or a population,
thereby facilitating cure, or reducing or
preventing it spreading or its long-term effects
(e.g. screening, case finding and early
diagnosis)
Action taken to avoid or remove the cause of a
health problem in an individual or a population
before it arises. Includes health promotion and
specific protection (e.g. immunization)
I
II
III
IV
IIItertiary prevention
IVquaternary prevention
Action taken to reduce the chronic effects of a
health problem in an individual or a population
by minimizing the functional impairment
consequent to the acute or chronic health problem
(e.g. prevent complications of diabetes).
Includes rehabilitation
Action taken to identify patient at risk of
overmedicalisation, to protect him from new
medical invasion, and to suggest to him
interventions, which are ethically acceptable
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Quaternary prevention shapes numerous concepts

• auto control of preventative and curative program
• careful analysis of miscommunication
• understanding of patients anxiety and belief
• defensive medicine
• accepting to decide in uncertainty
• humility in the diagnostic process and patient
  relationships
• ethically balanced attitudes

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• Quaternary prevention is more than prevention
• Its a style
• A way of thinking about our job.