Building A Fund of Knowledge for Community Medicine.
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Transcript of Building A Fund of Knowledge for Community Medicine.
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Building A Fund of Knowledge for Community Medicine
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It is a safe rule to have no teaching without a patient for a text,and the best teaching is that taught by the patient himself.
- Sir William Osler
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Mattie
• 67-year-old African American female
• Long history of type 2 diabetes
• Admitted with progressive shortness of breath
• Evaluated appropriately with history, physical exam, lab, x-ray, echocardiogram
• Silent myocardial infarction and congestive heart failure
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Mattie, continued
• From a CV standpoint, she did well
• Blood sugars were poorly controlled
• “Non-compliant”
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Mattie’s Vices
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ADA Diet, Board Exam Prep
• Which of the following would NOT be considered the most healthful food choices for an individual with type 2 diabetes?
A. Fresh fruits and vegetables
B. Dried beans
C. Fatback and buttermilk
D. Whole grain foods
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We don’t always tell the truth.
We don’t always know the truth.
The Truth
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ABCs of Preventive Cardiology
• A – Aspirin/antiplatelet; ACE
• B – Beta blocker
• C – Cholesterol; cigarettes
• D – Diabetes;
• E – Vitamin E; Estrogen; Exercise
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ABCs of Preventive Cardiology
• A – Aspirin/antiplatelet; ACE/ARB
• B – Beta blocker
• C – Cholesterol; cigarettes
• D – Diabetes;
• E – Vitamin E; Estrogen; Exercise
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We don’t always tell the truth.
We don’t always know the truth...
The Truth
Yet!
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Aristotle’s Intellectual VirtuesWays of Knowing
• Techne
• Sophia• Episteme
• Phronesis
• Nous
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Quality of Evidence
• Level I: Evidence obtained from at least one properly designed randomized controlled trial.
• Level II-1: Evidence obtained from well-designed controlled trials without randomization.
• Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
• Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
• Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
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The Scientific Method
• Experience: start from observation
• Conjecture: formulate hypothesis
• Prediction: reasoning from hypotheses
• Experiment: testing these elements
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Characteristics
• External
• Third person
• Dispassionate
• I-It
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Classic Experimental Design
Pre- Intervention Post-
Experimental
GroupO X O
Control
GroupO O
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Challenges of Communities
• Complex organisms
• Chaotic
• Non-linear
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People are Messy!
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Simple Complex
Rigorous
Not so much
?
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How do we embrace
a broader range of ways
to generate new knowledge,
while still retaining rigor?
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Anxiety about “Community”
• Focus?– Primary care– Indigent
• Imagery
• Content– Community college?
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The “Honors College”A Value-Added Curriculum
• Traditional biomedical curriculum
• Biopsychosocial model
• Public health themes/content
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Community MedicineFrom Molecule to Culture
Molecule
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Public Health Disciplines
• Biostatistics
• Epidemiology
• Health Administration and Policy
• Health Promotion Sciences
• Occupational and Environmental Health
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Certificate in Public Health
• Biostatistics
• Epidemiology
• Social and Behavioral Sciences in PH
• US Health Care Systems
• Environmental Health
• Integrated Public Health Practice
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Who Will Keep the Public Healthy?
• Epidemiology• Biostatistics• Environmental health• Health services
administration• Social and behavioral
sciences• Informatics
• Genomics• Communication• Cultural competence• Community-based
participatory research• Global health• Policy and law• Ethics
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Training Physicians forPublic Health Careers
• Leadership
• Public health emergency preparedness
• Clinical and community preventive service provision
• Across contiunuum of medical education
• Regardless of specialty
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Medicine is the most humane of sciences, the most empiric of arts, and the most scientific of humanities.
- Edmund PellegrinoHumanism and the Physician
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Re-visiting Mattie
• How would the perspective of a provider trained in community medicine enhance her care?
• How have or can public policy and public health practice impact her care?
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Outside the doctor-patient relationshipthere is a wider placefilled with community. And it calls to usthrough the voice of public health.
- Author unknown