CONFERENCE * CONFERENCE

Preventive medicine tries to move from under high tech's shadow Peter P. Morgan, MD, DPH H as the time finally come for physicians to make preventive services a major part of their clinical practices? If a recent 21/2-day policy conference in Ottawa is any indication, it has. The conference, Enhancing the Provision of Preventive Services by Canadian Physicians, was sponsored by the CMA and the Health Services and Promotion Branch of the Department of National Health -and Welfare and brought together 60 invited participants. Working in small focus groups, they tackled six subject areas: the practice setting, community interactions, information/application, medical education, continuing education, and tools. Each group was to develop visions of a future, 5 years hence, in which physicians and allied health personnel are finally fulfilling their promised roles in prevention. A second phase involved the creation of interest groups centred around the six topics. Although most participants were physicians, predominantly from universities or government agencies, medical educators, nurses and health care administrators were also represented. Organizer Dorothy Strachan told a planning meeting that "the Peter Morgan is a CMAJ consulting editor.

Those who now receive the best preventive services

need them the least. may

Dr. Richard Goldbloom

will produce better information than the speaker can generate". Nevertheless, keynote speakers Dr. Richard Goldbloom, chairman of the Canadian Task Force on the Periodic Health Examination, Dr. Hedy Fry, president-elect of the British Columbia Medical Association, and June Callwood, journalist and social activist, did more than motivate. Their presentations were designed to strong-arm participants into accepting a broad vision of prevention. In recalling a preceptor's in"the physician's misjunction sion is to relieve anxiety" Goldbloom may have established the conference's latent theme. The process

patient's quest for relief of anxiety about disease symptoms is being supplemented by a desire to get the best, most authoritative, health-related advice from physicians. To provide that, doctors may have to dispense health promotion the way they now hand out prescriptions. However, not everyone demands preventive care. Inequities, Goldbloom emphasized, need to be worked out: those who now receive the best preventive services may need them the least, while those who need them the most don't get them. Callwood, who proved to be as intense and moving an after-dinner speaker as she is an author, portrayed her CAN MED ASSOC J 1990; 142 (10)

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The chain of events leading hospice and her home for disadvantaged women as typical of the from the identification of individsorts of facilities the health care ual risk to "successful" prevention system and conventional physi- is longer than the chain of diagnosis, treatment and compliance. An cians could provide but don't. Goldbloom's theme of "the intervention - a vaccination, for doctor's mission to alleviate anxi- instance - may be proven efficaety" was echoed in many of the cious, but there may still be a sessions and it sounded a lot like a debate about the best way to profull-time job. The small groups tect a population. Public demand, began by agreeing that physicians a major mover in the process, should try to satisfy public expec- may not favour the interventions tations, as long as they are based known to be most successful. on feasible and reasonably valid Some of the most useful prointerventions for prevention. grams, such as smoking cessation, What should they avoid? The have a low, slow yield that sets overselling of prevention and the them in contrast to high-technolounnecessary labelling of people at gy magic. Some of the prevention risk, especially when no valid pre- interventions discussed at the vention strategy is available. This, meeting may, in fact, never be of course, requires that all physi- subjected to the type of randomcians set practice policies suitable ized controlled trial evaluations to their abilities and practices, clinicians have come to expect. Clinicians admit that they are possibly offering a slate of options tailored to several patient profiles. looking for guidelines from expert In doing this, the physician should groups. Conflicts between the rechave an active referral and con- ommendations of consensus consulting network involving allied ferences, although inevitable, are health professionals and com- damaging. As Goldbloom put it: "When consensus is needed as a munity agencies. As the conference began basis of public policy it may be a Marie Fortier, director-general of signal that the underlying facts are the Health Services directorate, shaky." Who, then, will be the clear said physicians could prepare to meet public expectations by tran- authority for such guidelines? Can scending institutional barriers and Jo111 Aledland stepping over professional boundaries. In this radical view physicians could be seen as working outside the framework of a practice based on individual patients, following credible guidelines and acting as agents of public health policy. They would not merely be treating patients, but addressing social goals such as improving cervical cancer screening rates in certain priority groups, or fighting drug abuse. Prevention activities, designed to forestall relatively rare events, are intrinsically harder to evaluate than therapies. As one participant put it: "The dimensions of curative medicine are much more sharply defined than those of preventive medicine." Callwood: some services scarce 1116

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government or professional agencies act as honest brokers between the setters of the guidelines and the implementers? This truly seems to be the era when, to cite a recent cartoon caption, "There are no great men, only great committees." The participants favoured a structured approach to this problem. Physicians might act on guidelines emanating from a carefully integrated process involving government, the profession and lay representatives, one that integrates the recommendations of task forces into a scheme of priorities. It was felt that both physicians and consumers of medical care, who will be increasingly affected as guidelines turn into standards of practice and even laws, will be more compliant if they have established "ownership" by participating in the development of consensus. Meanwhile, it seems, physicians will have to rely on the interplay between their own informed judgement and the factors that motivate and sustain the often unrewarding practice of preventive medicine. But are they being educated, or can they be, for this mission? Participants seemed ambivalent about the prospects of increasing the preventive component in medical education. Some urged that conventional medical education be broadened to include community service and training in health promotion services. However, there was a sense that established faculties, rigid curricula and the lack of role models at conventional medical schools were almost insurmountable obstructions to increasing the teaching of clinical prevention beyond its current level - 4% of teaching time. Dr. Paul Montambault, director of professional services at Quebec's Centre hospitalier universitaire de Sherbrooke, agreed, but held out renewed hope for the medical curriculum. His school is

one of the few founded on the radical problem-oriented curriculum, which seeks to replace hard, fragmented knowledge with small, self-directed student groups that acquire knowledge as they undertake specific tasks. The patient, not the disease, becomes the fulcrum for learning. However, some of the few schools that have embraced these "new" curricula are already backtracking. Continuing medical education (CME) will have to take up the slack. More research on changing physician learning and behaviour patterns is needed, and preventive components must be skilfully linked with other topics so that a 3-day course in prevention is not perceived as a 3-day bore. Nevertheless, as Dalhousie University medical educator Karen Mann put it, "CME can be effective if it is done right. Studies already show that CME works when it really helps physicians develop skills suitable to the practice environment." Although it is a given that clinical prevention is a low-technology area, participants still felt they needed some tools to do the job better. Dr. Martin Bass, a professor of family medicine at the University of Western Ontario, noted that one-third of the physicians he surveyed already have recall systems to alert patients to the need for preventive care. However, participants wanted better monitoring and information systems, everything from pamphlets to patient-held records to a clearinghouse for prevention information that could be tailored to specific patient and practitioner profiles. Just like surgical instruments, such tools will cut better in some hands than in others. Women practitioners, younger doctors and recent graduates are more likely to pursue active prevention and health promotion programs, Bass noted. And this may be the profile of the physician most likely to

Most Canadians trust physicians and the advice they offer. "Use the leverage this trust provides." Dr. Hedy Fry

interact successfully with the community health network. David Butler-Jones, the medical officer of health for Ontario's Simcoe County, represented the Canadian Public Health Association at the meeting, and noted that there is little information on the interaction between practitioners and the community. He said it is essential that physicians who spearhead the prevention/promotion effort be acceptable to doctors interested in public health and those interested in private practice. Participants felt that physicians need a strong core of validated tasks and achievable goals. One way to meet this need is to concentrate on the "A" and "B" recommendations of the Canadian Periodic Health Examination Task Force. Interventions favoured with these high ratings are the most likely to be scientifically valid. The way physicians perceive their success in prevention, said Bass, is strongly related to the proven validity of the manoeuvre they're working with. In one survey more than 85% of physicians felt they were doing a good job in diagnosing and treating hypertension, while only 5% felt the same about their effectiveness in smoking cessation programs.

Prevention in clinical practice idea whose time has come times. "The physician's role is fast becoming social and preventive", Abraham Flexner wrote in 1910, "rather than individual and curative. Upon him society relies to ascertain, and through measures essentially educational to enforce, the conditions that prevent disease and make positively for physical and moral wellbeing." Unfortunately, the intervening years have not dealt kindly with this prognosis. Still, medical educators, public health advocates and, now, patients themselves, are clamouring for physicians to play a leadership role in preventing disease and premature death. Are there any new and encouraging signs that this will happen? Hedy Fry reminded physicians that 80% of the population trusts them and the advice they offer and urged them to use this as leverage. To extend her metaphor, the long handle of the lever would be scientific validity and the short, working end would be implementable programs. And all of it would depend on how well the fulcrum the capability and credibility of health care professionals could take the pressure.is

an many

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Preventive medicine tries to move from under high tech's shadow.

CONFERENCE * CONFERENCE Preventive medicine tries to move from under high tech's shadow Peter P. Morgan, MD, DPH H as the time finally come for physi...
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