preventive medicine, preventative medicine

April 29, 1995

Kevin Patrick, MD, MS
F. Douglas Scutchfield, MD
American Journal of Preventive Medicine
San Diego State University
5500 Campanile Drive
San Diego, CA 92182-4710

Dear Editors,

When I received notice that I had passed my board certification, I did what any good daughter would do - I called my father to tell him the news. "Hey, Dad!" I exclaimed, "I passed my boards!"

"In what?" came his immediate reply. He was genuinely confused about my professional identity. Having gone the traditional path of pathology, he had trouble understanding how completing an internship in pediatrics, earning a Master's degree, then taking a position as a federal investigator could translate into anything but board certification in confusion.

"Preventive Medicine, Dad," I said, somewhat impatiently. I briefly outlined the concepts of epidemiological research and health education for him. "Oh, I see," he finally said. "Preventive medicine. You are trying to prevent medicine."

I sighed and thought, do all pathologists have this strange sense of humor or is it just my father? "Yes, Dad, that's exactly right - I'm trying to prevent medicine. My goal is to try to put all the other doctors out of business. I don't know if I'll succeed, but I'll give it my best shot."

When I chose the path of Preventive Medicine, I thought I was choosing a career in public health research, and indeed, most of my professional path has been one of epidemiological research and public health administration. However, two years ago, I began seeing myself as a preventive medicine physician rather than a public health specialist, and found myself on the cutting edge of medicine.

Historically, the role of physicians has been to take care of the sick, and the role of hospitals has been to assist physicians with caring for their patients. The majority of us - patients and physicians alike - still think of hospitals as a place to go when we suspect disease, whether for early detection, diagnosis and/or treatment. There has been a gradual but major shift away from self-responsibility for health. Past and current systems of cost re-imbursement and dramatic changes in the sophistication and technology of disease diagnosis and treatment have contributed to this shift. People not only expect us to fix them up as good as new, they expect insurance companies - designed to cover catastrophes not every day health care - to foot the bill, even when they recognize that their own behavior and choices have contributed to their disease. As our local health care delivery systems continue to shift toward capitation-based reimbursement, and our primary care physicians evolve from disease consultants into health consultants, we need to support them with usable information and tools on wellness. If community-based hospitals are to continue their primary role as support systems for physicians, they need to become places that assist people with taking responsibility for their own health, and become facilitators of both healing and wellness.

We know that physical health is impacted by an immense array of variables. Our genetics, physical environment, lifestyle, social support, thoughts and emotions all contribute to our physical well-being, in addition to contributing to our mental and emotional well-being. Think of these health variables as a mobile over a baby's crib - move one, and they all move, each having an equal ability to set the others out of balance. Unlike physicians in other cultures, physicians in this country have been trained to approach health almost exclusively from a biochemical viewpoint. The vast majority of our prevention tools are technological and are secondary prevention tools, based in the physical sciences and designed to decrease prevalence rather than reduce incidence of disease. The majority of primary prevention interventions involve changing lifestyle behaviors, attitudes, and how we process our emotions - techniques most physicians are not taught in medical school. We need to borrow methods from our colleagues in psychology, behavioral medicine and education as well as from the medical toolboxes of other cultures. Research physicians such as Herbert Benson, Dean Ornish, Michael Sacks and Karen Olness are documenting the powerful therapeutic and preventive benefits of using our minds and lifestyles to improve our physical health.

What should a properly trained clinical preventive medicine specialist be able to do? 1) Epidemiologically assess the need for specific preventive services on a community, hospital and office practice level and design and implement appropriate interventions; 2) Direct a wellness center for all ages that includes fitness training, nutritional guidance, behavioral modification assistance, group support programs, and a wide variety of stress management modalities; 3) Direct a health information and educational center that includes computer on-line searches, conference planning, and the preparation and presentation of written, verbal, and experiential programs for professionals and the community. 4) Assess an individual client for a wide variety of health risk factors, including genetic and personality predispositions, lifestyle, social, behavioral and emotional risk factors, and develop a feasible customized wellness 'prescription' designed to improve and maintain quality of life.

Although employed by community hospitals, we would work closely with area schools, community and civic groups, local government and public health officials to identify areas of concern and design and implement interventions, serving as both a consultant and coordinator. As a clinician, we would work as a consultant to both primary care providers and specialists. For example, the cardiologist would work up and treat the acute myocardial infarction, identify underlying biochemical and physical risk factors such as high serum cholesterol, then refer the patient to a clinical preventive medicine specialist. Our responsibility would be to work with the primary care physician in assessing all health risk factors, in this case focusing on heart disease. We would then recommend various interventions and assist the patient with making the necessary lifestyle changes such as getting to the gym, cooking classes, anger workshops, etc. The cardiologist and primary care physicians would retain the responsibility of monitoring the status of disease and the impact of the interventions. Essentially, we would become wellness specialists.

The curriculum for a clinical preventive medicine specialist would focus as much on individual as population assessment and intervention. Epidemiology courses would focus on working with small data sets as would be found with auditing office and ER records and investigating small clusters of disease/injury in a community. Preventive Medicine Residents should also receive extensive training in how to access information through both the public and private domain, including conducting on-line literature searches of NLM databases and understanding how to access useful information from the federal and state government. Experience with conference planning, teaching and making formal and informal written and verbal presentations is essential. We also need to be trained in education and counseling techniques such as group process, personality test administration, and behavioral modification techniques. Last, but not least, we need to greatly expand our knowledge and ability to implement fitness, diet, stress management and other primary prevention programs.

As evidenced by the N.Y. Times Best Sellers List, the success of television programs such as Bill Moyer's "Healing and the Mind", and the increasing number of articles about complimentary medicine in mainstream and professional magazines and publications , our culture is increasingly moving towards the belief that health is at least in part, mental, physical and spiritual. Wellness programs need to incorporate these beliefs if they are to be successful in the community.

As the body of research and knowledge on how our lifestyle, thoughts and emotions contribute to our physical ability to heal and/or stay healthy expands, we will need to add additional primary prevention tools to our medical bag. Although I believe that many complimentary therapies may have a role in preventing mental and physical disease, I am still uncertain of their role as a treatment or cure for physical disease. As the National Institutes of Health's Office of Alternative Medicine progresses with its mission, we need to stay open-minded to its findings. Many of the modalities being explored through this institute are used as primary and secondary prevention methods in other cultures.

The successful functioning of the U.S. health care system will increasingly depend on each of us taking responsibility for our own health and customizing a prevention strategy. Most of us have forgotten, or never knew, that the Latin word "doctor" (from doc re) means "to teach". Perhaps more than any other medical specialty, the role of the preventive medicine doctor is to teach - to teach the community, teach our fellow physicians, and teach our neighbors how to live healthier lives.

Sincerely,

Joy Koenig, MD, MS

(a significantly shortened version of this letter was published in AJPM: Koenig, J. Clinical Preventive Medicine Specialist. American Journal of Preventive Medicine, 12:2 Mar/Apr 1996.)