about prevention : the quaternary prevention
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Marc Jamoulle , Family doctor & researcher Members of the Wonca international Classification Committee Centre académique de médecine générale , UCL, Brussels, Belgium. About prevention : the quaternary prevention. 15th Wonca Europe Conference 32nd SSMG/SGAM Congress - PowerPoint PPT PresentationTRANSCRIPT
Marc Jamoulle, Family doctor & researcherMembers of the Wonca international Classification CommitteeCentre académique de médecine générale, UCL, Brussels, Belgium
1MJ 2009
15th Wonca Europe Conference32nd SSMG/SGAM Congress16–19 September 2009, Basel, Switzerland
The Fascination of ComplexityDealing with Individuals in a Field of Uncertainty
A determined Process About a vulnerable Problem
In due time
Primaire Secondaire Tertiaire
Healthpromotion
Specific protection
Diagnose &Early treatment
Disability limitation
Rehabilitation
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.
Chronological approach, provider centered1958
MJ 2009 4
Chronological approach, provider centered
Primary Secondary
Onset of the
problem
Ex : “secondary “ prevention of relapse by Aspirin after acute coronary heart disease
A process about a problem along the time line
5MJ 2009
Could be very different from
Patient’s views
Doctor’s views
Cognitive and Chronological approach, patient centered
MJ 2009 6
Mixing patient’s and doctor’s views in primary care
Onset of the
problem
You are
I am
MJ 2009 7
Mixing patient’s and doctor’s views in primary care
Onset of the
problem
You are not
I’m not
MJ 2009 8
Mixing patient’s and doctor’s views in primary care
Onset of the
problem
You are
I’m not
MJ 2009 9
Mixing patient’s and doctor’s views in primary care
Onset of the
problem
You are not
I am
Crossing doctor and patient’s views Time line is no more the
central issue
Between disease and illnessBetween science and conscience
Between patient and doctor
Disease
Illn
es
_ +
_
Doctor
Pati
en
t
11MJ 2009
+
Time line
α
Ω
12
I
III
DiseaseIl
lnes
_ +
_
+
DoctorP
ati
en
t I II
IIIIV
Crossing patient and doctor thoughts open four interpretation fields
MJ 2009 12
I
III
DiseaseIl
lnes
_ +
_
+
DoctorP
ati
en
t I
Patient feel him/herself well
Doctor can find nothing wrong
Primary prevention
Ex: Immunization or prevention of falls
13MJ 2009
I
III
DiseaseIl
lnes
_ +
_
+
DoctorP
ati
en
t II
Ex: screening
Cervix/ Breast/ Scoliosis
Secondary prevention
14MJ 2009
Patient feel him/herself well
Doctor look for disease. The doctor bets on the disease.
I
III
DiseaseIl
lnes
_ +
_
+
DoctorP
ati
en
t
III
Tertiary prevention
Ex: retinopathy prevention in diabetic patients
Aspirin in post infarctus
15MJ 2009
Patient feel him/herself sick
Doctor agrees and looks for complications
II
I
III
DiseaseIl
lnes
_ +
_
+
DoctorP
ati
en
t
Primary
prevention
Secondary
prevention
III
Tertiary
prevention
What about the remaining one ?
16MJ 2009
We got three
III
Patient feel sick
Doctor can find nothing wrong
DiseaseIl
lnes
_ +
_
+
DoctorP
ati
en
t
IV
17MJ 2009
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
As published in the
Wonca Dictionary of General/Family Practice
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
19MJ 2009
IPrimary 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
IIsecondary prevention
20MJ 2009
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
IIItertiary prevention
21MJ 2009
I
III
DiseaseIl
lnes
_ +
_
+
DoctorP
ati
en
t
IV
Primary
prevention
Secondary
prevention
III
Tertiary
prevention
22MJ 2009
Ex : Unfit health prevention campaign
III
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…..
I
III
DiseaseIl
lnes
_ +
_
+
DoctorP
ati
en
t
IV
Primary
prevention
Secondary
prevention
III
Tertiary
prevention
23MJ 2009
Ex : non targeted breast campaign
III
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…..
I
III
DiseaseIl
lnes
_ +
_
+
DoctorP
ati
en
t
IV
Primary
prevention
Secondary
prevention
III
Tertiary
prevention
24MJ 2009
Ex : 3 mm angioma in the liver
III
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…..
I
III
DiseaseIl
lnes
_ +
_
+
DoctorP
ati
en
t
IV
Quaternary prevention
25MJ 2009
Listen to the patient
Control medicine
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
IVquaternary prevention
26MJ 2009
I II
IIIIV
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
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)
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)
IIItertiary prevention
IIsecondary prevention
IPrimary prevention
IVquaternary prevention
27MJ 2009
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 28
Quaternary prevention is more than prevention
It’s a style
A way of thinking about our job.
MJ 2009 29