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