About prevention : the quaternary prevention

1. Marc Jamoulle, Family doctor & researcher Members of the Wonca international Classification Committee Centre académique de médecinegénérale, UCL, Brussels, Belgium About prevention :the quaternary prevention 15th Wonca Europe Conference 32nd SSMG/SGAM Congress 16–19 September 2009, Basel, Switzerland The Fascination of Complexity Dealing with Individuals in a Field of Uncertainty MJ 2009

2. 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

3. 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.

4. Chronological approach, provider centered A process about a problemalong the time line Secondary Primary Before After Onset of the problem Ex : “secondary “ prevention of relapse by Aspirin after acute coronary heart disease MJ 2009

5. Cognitive and Chronological approach, patient centered Doctor’s views Could be very different from Patient’s views MJ 2009

6. Mixingpatient’s and doctor’sviews in primary care Onset of the problem You are I am MJ 2009

7. Mixingpatient’s and doctor’sviews in primary care Onset of the problem You are not I’m not MJ 2009

8. Mixingpatient’s and doctor’sviews in primary care Onset of the problem You are I’m not MJ 2009

9. Mixingpatient’s and doctor’sviews in primary care Onset of the problem You are not I am MJ 2009

10. Let us see those concepts in a different way Crossing doctor and patient’s views Time line is no more the central issue Between disease and illness Between science and conscience Between patient and doctor

11. α _ + Doctor Disease _ Patient Illnes Time line + Ω MJ 2009

12. _ Doctor + Disease _ Patient Illnes I I II + III IV III Crossing patient and doctor thoughts open four interpretation fields 12 MJ 2009

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 MJ 2009

14. _ 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 MJ 2009

15. _ 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 MJ 2009

16. _ 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 ? MJ 2009

17. _ Doctor + Disease _ The anxiety of the patient meets this one of the doctor You have nothing - It’s 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…… It’s the field of chronic fatigue syndrome but also of not yet diagnosed Multiple Sclerosis Patient Illnes + IV MJ 2009

18. Let us have a look back at the definitions As published in the Wonca Dictionary of General/Family Practice

19. 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 MJ 2009

20. 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 MJ 2009

21. 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 MJ 2009

22. 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 MJ 2009

23. 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 MJ 2009

24. 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 MJ 2009

25. _ Doctor + Disease _ Patient Illnes I Quaternary prevention + III IV Listen to the patient Control medicine MJ 2009

26. 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 MJ 2009

27. I Primary prevention 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) 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 IVquaternary prevention 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 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 MJ 2009

28. Quaternary prevention shapes numerous concepts • auto control of preventative and curative program • careful analysis of miscommunication • understanding of patient’s anxiety and belief • defensive medicine • accepting to decide in uncertainty • humility in the diagnostic process and patient relationships • ethically balanced attitudes MJ 2009

29. Quaternary prevention is more than prevention It’s a style A way of thinking about our job. MJ 2009