The Many Facets of Preventive Medicine
A January 19, 2017 article on the website of the American College of Preventive Medicine ran with the headline, Preventive Medicine’s Identity Crisis. Authors Dr. Boris Lushniak and Dr. Paul Jung posed this question: “What is preventive medicine? Specifically, what is the specialty of preventive medicine, and how should it best be described?”
The physicians explained: “The specialty of preventive medicine is poorly understood, not only by the medical profession and the general public, but even among some of its practitioners. Currently, there is no unifying, vernacular explanation of the specialty of preventive medicine, to its detriment.”
The confusion isn’t so difficult to understand; within the term ‘preventive medicine’ care are a number of specialties and subspecialties.
From the American Board of Preventive Medicine:
• Preventive Medicine is the specialty of medical practice that focuses on the health of individuals, communities, and defined populations. Its goal is to protect, promote, and maintain health and well-being and to prevent disease, disability, and death.
Preventive medicine has three specialty areas with common core knowledge, skills, and competencies that emphasize different populations, environments, or practice settings: aerospace medicine, occupational medicine, and public health and general preventive medicine.
• Public health and general preventive medicine focuses on promoting health, preventing disease, and managing the health of communities and defined populations. These practitioners combine population-based public health skills with knowledge of primary, secondary, and tertiary prevention-oriented clinical practice in a wide variety of settings.
• Occupational medicine focuses on the health of workers, including the ability to perform work; the physical, chemical, biological, and social environments of the workplace; and the health outcomes of environmental exposures.
• Aerospace medicine focuses on the clinical care, research, and operational support of the health, safety, and performance of crewmembers and passengers of air and space vehicles, together with the support personnel who assist operation of such vehicles.
Additionally, the ABPM has traditionally identified three subspecialties within preventive medicine: Clinical Informatics, Medical Toxicology and Undersea/Hyperbaric Medicine. In March 2016, the American Board of Medical Specialties announced the recognition of Addiction Medicine as a new subspecialty under the APBM.
So it’s small wonder that preventive medicine might be suffering an identity crisis. With so many individuals, populations and communities falling under one or more of these categories, the lines between and among specialties can be blurred.
On a recent Monday morning on the campus of Eastern Virginia Medical School, Dr. Christine Matson, professor and chair of the Department of Family and Community Medicine, was talking to a class of third-year medical students about prevention. The class was reviewing a series of scenarios previously given to them, in which they were asked to identify preventions, sources they relied on, principles of preventive medicine, and whether the scenario involved primary, secondary or tertiary prevention.
One case involved a 9-month old infant. The responding student addressed the issue of injuries, and listed preventions that included installing rear-facing car seats, installing smoke detectors in the home, and importantly, ensuring babies sleep on their back, with all objects removed from the bed. Her source was the Academy of Family Physicians. The scenario involved primary preventive medicine.
While the students considered several other scenarios, Dr. Matson emphasized the tendency of some people to think that the reason others get sick (other than genetics), is because they aren’t doing the right things, or they don’t know the right things. “Educational deficits is certainly part of it,” Dr. Matson told them, “and having a good education and being health literate correlates well with improved health for the future – but education isn’t enough. The fact is that too many of our dollars go to treatment rather than to prevention.”
Dr. Michael Levine, a preventive medicine specialist in Williamsburg, Virginia, agrees. “The goal of primary prevention is to prevent new disease by reducing risk factors, or to prevent the onset of preventable conditions. Not smoking significantly reduces the risk of developing lung cancer. Eating well avoids diabetes. Fluoride in the water prevents caries. The problem is, nobody wants to pay for prevention. It’s hard to sell and very easy to defund.”
In secondary prevention, Dr. Levine continues, “disease is at its incipient stage, when it’s possible to walk it back completely, or at the least, make the outcome better. Losing excess weight can slow or stop diabetes. In the case of noise-induced hearing loss, for example, we may not be able to reverse it, but we can prevent further loss.” Screening procedures are often the first step in secondary prevention.
Tertiary prevention’s goal is to reduce the damage caused by symptomatic disease, and to prevent further pain and damage, halt progression and complications from disease, and to the extent possible, restore the health of patients affected by disease. Still, “It’s not surprising that so many of our health care dollars go to treatment rather than to prevention,” Dr. Levine says, “despite the fact that primary prevention would probably save a lot more money than any curative activity.”
Both Dr. Shannon Blackmer, LCDR, a preventive medicine physician with the US Navy and Marine Corps Public Health Center in Portsmouth, and Dr. Donald Hastings, a primary care physician with Bon Secours Patient Choice Oceana in Virginia Beach, have seen first hand what happens in the absence of strong preventive medicine.
Dr. Blackmer assists a team with planning Global Health Engagements in Central and South America. In the summer of 2015, she deployed in support of Southern Partnership Station, an annual series of US Navy deployments focused on subject matter expert exchanges with partner nation militaries and civilian medical personnel in Central and South America and the Caribbean. She continues to plan engagements for this mission. US military teams work with partner nation forces during naval-focused training exercises, military-to-military engagements and community relations projects in an effort to enhance partnerships with regional maritime activities and improve the operational readiness of participants. “We’re trying to build our partner countries’ capacity to improve their health, to teach them things they can teach others in their country to improve their overall health structure.”
She describes the conditions she found: “We went to a very small clinic and met the local medical staff. They were in the middle of a vaccination drive. I asked how they were able to keep track of the children who had been vaccinated. One of the nurses pulled out a very large, very old book, and showed me page after page on which the children’s names had been handwritten. This was their only record.”
Dr. Hastings has seen similar circumstances. “I’ve done a lot of overseas work, in Africa, where our hospital was filled with patients who had preventable illnesses – like diarrheal illnesses caused by unclear water,” he says. “We saw tuberculosis, malaria, meningitis – the same patients with the same conditions over and over, conditions that could have been prevented through simple changes like adding bed nets and spraying.”
Dr. Hastings spent time in China, as well, which he says was doing better than Africa, but still lagged far behind the US. “We were in an area with a great deal of HIV infection,” he says, so we did public health training as well as treating patients.”
In daily practice as primary care physicians, Dr. Hastings says, “We’re at the forefront of taking care of patients, and preventive medicine is the key. A big part of our job is being sure that patients are up to date on preventive screenings.” For a primary or family care practitioner, it can be frustrating, Dr. Hastings says, “because every specialty has its own academy with its own guidelines, and they can sometimes conflict with others.”
Dr. O. T. Adcock, an administrator and family medicine physician with the Riverside Health System, agrees: “Many different societies publish recommendations, and they’re often in agreement or very similar. But occasionally there’s disagreement – for instance, at what age should women start getting mammograms and how often? It’s the same with the PSA test – some guidelines say stop doing at 75, but if I have a patient who’s that age or older, who’s otherwise very healthy and likely to live a decade or more longer, I’ll certainly order the test. A lot depends on the individual patient. That’s when we prove that medicine is as much an art as a science.”
Both Dr. Adcock and Dr. Hastings rely heavily on the guidelines set forth by the United States Public Health Service Task Force.
Establishing the guidelines under which primary care physicians operate is the bailiwick of preventive medicine specialists like Dr. Levine, whose practice takes him to several locations each week: a federal agency one day where he’s the onsite occupational medicine doctor, or a clinic in Williamsburg where he evaluates employees to determine whether they can safely perform their assigned jobs. He performs medical qualification exams, commonly done on employees with safety sensitive jobs: police officers, firefighters. Additionally, he looks at workplace settings of employees with specific medical conditions, and helps find ergonomic solutions that make that workplace work for them.
“We really focus on function,” Dr. Levine explains. “I can clear a bus driver in his eighties for a short duration, while denying clearance to a 40-year old with a disqualifying condition. If we’re doing our job correctly, we’re setting the stage for workers to remain on the job safely, without injury, for as long as they want to be there.”
Workers can perform their jobs in the air or under water, as well as on the ground. As a former flight surgeon, Dr. Blackmer ensured that pilots were safe to fly, without injury or illness, and not taking any form of medication that could interfere with their ability to be in the cockpit. When incidents did occur, she participated in accident investigations as well.
A New Definition for the 21st Century
Dr. Lambert Parker, who maintains a private practice in Virginia Beach and also serves as Medical Director of Integrative Longevity Institute of Virginia, takes an ecological approach to preventive medicine, and genetics plays a large role. He is a proponent of the Human Biome Project, which was established in 2008. “The HBP is the collection of all of the microorganisms living in association with the human body,” Dr. Parker says, “and because of our newfound and ever expanding knowledge of genomics and microgenomics, new cognitive tools are letting us see the world and biology in a different way.
“We can’t continue to prevent problems by giving a shot. People are getting more obese every day, while there’s a gym on every corner,” Dr. Parker says. “We’ve beaten the things that were catastrophes for our forefathers – malaria, typhoid, leprosy – but human beings aren’t healthier and more productive. We’re living longer, but sicker. We have to address these problems from a 21st century perspective.”
Dr. Matson agrees. “We need to think about primary prevention and the ways we’ve designed our environment that have greatly increased the incidence of chronic diseases in our population. We still don’t have all the information we need, and all you have to do is open the Internet to see all the products being advertised as tonics and cure-alls, to know that there’s a huge number of dollars being spent on pills, because people are looking for an easy way to be healthy.”
“We’re making some progress,” says Dr. Adcock. “But people are still drinking sugary drinks, still smoking, still not exercising. These are the basics.”
Changing those three things might well be the health care revolution the country needs.
