Encounter in General Practice/Family Medicine is a meeting point between illness and disease. Looking at patients and doctors beliefs and attitudes, one can define four fields of activity describing the major working areas in GP/FM. Considering clinical prevention as the management of processes over a length of time, one can define four main prevention domains. This approach enables us to clarify the concepts of Primary, Secondary and Tertiary prevention while defining a new one: Quaternary prevention. The latter encompasses the consequences of the encounter between the anxiety of the patient and the uncertainty of the doctor and gives insight into the propensity of this kind of meeting to distil sickness, thus creating false positive with its cohort of avoidable human, social and economic costs and suffering
General practice, a world of complexity
- Theme one : Curative versus preventive scotomisation and discrepancies in the use of the term "Prevention" in medicine. Confusion between Primary and Secondary prevention concepts
- Clinical prevention is the management of processes over a length of time
- The term Primary and secondary are often used in mvedical papers as well in pharmaceutical adds in a wrong sense. Primary being used for secondary and secondary for tertiary. Following WONCA definition (WICC, 1995), to be at risk of cardiovascular event is typically the field of secondary prevention while some authors are using the acception of primary cardiovascular prevention in this issue.(Visentin, 2001)(xxx)
- The curative model concentrates solely on the goal of cure and in the process neglects medicine's other goal (Fox, 1997)
- The difference between investigation field (III) and screening field (II) is not so clear as previoulsly described (Ewart 2000). Under the pressure of the market and of defensive medicine, any presenting patient has to be checked for a lot of problem not pertinent to the presenting symptoms. Complaint and disease based medicine is still gliding more and more to risk management medicine.
- Theme two : patient doctor relationships and anxiety of both actors
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Balint views (Balint, 1964)
- Paradigm shift in the late 90th (Kehr L White : The Task of Medicine)(White, 1988) and GP at the interconnexion of various form of knowledge (Van Dormael, 2001)
- Some family physicians produce more somatisation than others but patients can control behaviour of their family physician by the timing, order, and nature of the symptoms they present. (Murphy, 1989)
- The general practitioner hold a key role in preventing of somatic fixation. Somatic fixation occurs when people come to depend from health professional or when they become trapped in a medical maze as a result of continuous process of inadequate reaction to illness, complaints or problems.(Grol,1988)
- Separately or together, patient and doctors can harm as well as heal and it is the learning skill of preventing harm that is one of the challenge facing general practitioners (Pereira Gray, 1988)
- Illness, the feeling of being unwell, is what brings patients to doctors. This is what people have when suffering from a disease, but also, when they have a condition whose cause we cannot explain. And illness is what doctors have to treat, whether by curing a disease with a specific remedy or by other means, such as using the “doctor as drug” effect, or using a placebo (Markus, 2000)
- About investigation and screening : Despite the increasing evidence that changes in ordering of investigations are necessary, when it comes to individual patients, their doctor's decision whether to investigate will always involve more than just scientific evidence(Winkens, 2002)
Table 1 : Four conceptual aeras in GP/FM.
(adapted with permission from Monique Van Dormael)
- Theme tree : the worried well and the uncertain doctor
- So many of the illnesses we encounter are such complex results of individual factors that they defy abstraction. We know that people can be seriously ill with little physical evidence of illness (McWhinney, 2000)
- In his seminal paper Discussing the overlap between diagnostic syndromes such hysteria, hypochondriasis, neurasthenia, somatisation reaction etc., Pilowsky highlight the concept of Abnormal illness behaviour. Addressing the diagnostic problem "presented by the patient with physical complaint for which no adequate organic cause can be found." He defines Abnormal illness behaviour as " The doctor does not believe that the patient's objective pathology entitle him to be placed in the type of sick role he expects, for the reasons which he claims it" (Pilowsky, 1969)
- Twenty five years later, after reviewing progressive move of ideas in this field through DSMII, DSMIV an ICD10, he describes "Abnormal Illness behaviour (AIB) in which the patient cannot accept the medical explanations and is preoccupied by an inaccurate view of his health status"(Pilowsky, 1994)
- This has also been addressed by Meador as "Nondisease syndrome" A Nondisease exist when a specific entity is suspected but not found. This is uncomfortable for both doctors and patients. Patients, when told of their overt nondisease for some reason tend to become hostile and difficult to manage. Nonanxiety becomes anxiety. (Meador, 1965)
- Looking for hidden reasons some patients visits doctor, Barsky (Barsky, 1981) concludes that persons consult physicians for psychological, social and informational reasons. Ignoring this fact would invariably lead to the the creation of "Functional somatic syndromes "(Barsky, 1999)
- A person, viewed as a mindbody complex, is in constant interaction with the environment. It follows that both study of mental illness and clinical practice need to take into account the psychological, the biological and the social aspect (Lipowski, 1989)
- Some patients with minor acute illness have exaggerated responses to common symptoms and become high users of medical care. These are probably recognized by many physicians as the “worried well". (Smith, 2002)
- Somatic distress and medically unexplained symptoms have always been endemic to daily life ( Barsky 1999 )
- In Somatoform disorder (SD), there is no diagnosable general medical condition to fully account for the physical symptoms (APA, 1994)
- Symptomatic diseases are on the bridge between well being and ilnesses , as Restlessleg or chronic fatigue syndromes, with a huge amount of secondary benefices if recognized (xxxnnn look for references) Some syndrome are so aspecific that one as to be familiar with the syndrome to diagnose it. Foundations are necessary to increase awareness of those symptom-diagnosis diseases.(Hening W, 2001).
- Worried well is not always "well". Nondisease or medically unexplained symptoms are associated with high rates of disability.Patients report poorer levels of physical and social functioning than those who receive a medical diagnosis (Reid,2002)
- The BMJ recently ran a vote on bmj.com to identify the "top 10 non-diseases (BMJ,2002), over almost 200 identified by responders. To have your condition labelled as a disease may bring considerable benefit. Immediately you are likely to enjoy sympathy rather than blame. (Smith,2002)
- To give a name to the complaint is he first step of medicalisation. Hypotension concept is a good example of such approach of the sensitive patient (Arya DK, 1996)
- Theme four : Prevention, medical economics, ethics and quality assurance to be integrated in daily practice
- The task of the GP/FM is changing and growing. (WONCA, 2002)
- Patients are very positive about general practitioner introducing topics related to prevention during an encounter (Hulshof, 1998)
- Prevention is a rapidly growing market, with huge investment. The worldwide global market for the Meningitis C vaccine is estimated at US $600 million per year (Lattanzi 2002)
- Functional somatic complaints constitute a large, clinically important and costly health care issue ( Wessely, 1999)
- Additional growth in medical care (technical capacity, shared resources) might actually produce harm (Fisher 1999)
- In screening, nonmaleficence almost always take precedence over beneficence ( Ewart 2000)
- Various way to understand the "Do not Harm" in health care economy. "Do not Harm" could be reduced to the 'informed consent" of the patient, not to a duty of beneficence (Sharpe, 1997)
- Selling sickness: the pharmaceutical industry and disease mongering Moynihan, 2002
A four fold vision allows conceptual integration of those premises
Patient doctor encounter, a meeting between science and conscience
The consultation, meeting between two human beings, one the patient, endorsing the sick role, the second, doctor, endorsing the therapeutic role, is also a meeting between knowledge and sensation. The doctor's knowledge, true or false, cross the thoughts, true or false, of the patient. In a certain way, the patient doctor encounter is a meeting between science and conscience. The word science, used here, encompasses the knowledge of the biological, mental and social being. By his/her training, the doctor drags irresistibly the patient towards the disease. It is his/her medical job to reveal it. He/she will be gratified to have , at least, found the evil, forcing back always the limits of the diagnostic exploration. This could partly explain the importance and the huge cost of defensive medicine
For his part, the patient, although mentally fit, is ineluctably and by life itself, draw towards the uncertain and frozen territories of the illness and death. He/she will resist with difficulty to the anxiogenesis of this civilisation in which disease involves social exclusion and for which body and healthy body are sacred values.
| Meeting Fadma, 30 - Maghrebian A dark patch on the nipple is worrying her. Preoccupied and stressed, she talks fast. She heard yesterday that a man committed suicide 10 years ago in the house she has just bought. She has herself already been possessed and was exorcized by a well-known Iman. She is afraid the evil spirits are preparing illness and death for her. Although her last mammography taken two months ago was negative, she wants to be sure this dark patch is not serious. She sits down and uncovers her breast. After being listened to, palpated and reassured, she leaves with her mind at rest. |
Meeting Elisabeth, 72 - Belgian The situation is preoccupying. This patient is being followed on a long term basis for breast cancer. The first error was to have ticked the CEA division instead of the CA 15-3 one. The CEA mark is very high and the patient whose husband died of colon cancer, understands immediately that the situation is serious. The colon by injection is negative and the control blood test shows normal. It was a false positive. She has already survived breast cancer and has nursed her husband so she knows the amount of suffering involved. She doesn't believe me, thinks I have tampered with the figures and requests another check. It will take several consultations, a lot of patience and listening to smooth away her doubts and regain her trust. |
MJ, surgery, Sept 2002
Decision in uncertainty
Medical doctors, as they are confronted to decision making, can best be understood by combining a probabilistic approach and a good knowledge of decision's context itself. Medical decision is partly rationalised and explicit, but it is also dependent on the doctor's psychology, partly implicit (due to the contingency of the doctor's models and values) and it is elaborated according to a Bayesian logic in a context of uncertainty. It is therefore statistically and subjectively founded ; only the mathematical process can be rationalised.The fundamental concept of a test encompasses any procedure with a decision purpose through which clinical facts can be confronted with a diagnostic hypothesis. This definition includes all elucidation interventions such as clinical biology, anamnesis, physical examination, imaging, para-clinical examinations, therapeutical tests, combination of the aforementioned or … abstention.
Classical characteristics of a test are sensitivity ( proportion of positive tests among the diseased persons) and specificity ( proportion of negative tests among the persons free of the disease). A highly sensitive test will miss only few "false negative" truly affected patients; on the contrary, a highly specific test will select only few "false positive" persons, free of the disease. The global quality of the test comes from the combination of both sensitivity and specificity.
But, what matters really for the clinician are two other characteristics which are less often mentioned : positive predictive value (PPV = proportion of truly affected persons among the total of positive tests : what is the probability for a person with a positive test to be affected by the disease ?) and the negative predictive value (NPV = proportion of persons truly free of the disease among the total of negative tests : what is the probability for a person with a negative test to be free of the disease ?)
Specialised doctors deal with populations of patients among which the prevalence of specific health problems is expected to be high, if the health care tracks are appropriately used, which means that the patients' population consulting at a certain level is effectively the one which is expected to consult at that level.. By prevalence one means the frequency (proportion) of a health problem in a well defined population at a certain time; one does not deal here with the frequency of the positive tests.
On the other hand, GPs deal with populations of patients of all kinds, unselected, and among which the prevalence of a specific disease is generally low. Their role is then to use their clinical "feeling", anamnesis and clinical examination in order to constitute suspicious sub-groups of patients where the prevalence is then expected to increase, before these selected patients can be exposed to the decisive tests or referred to specialists (selective access).
Their role is to manage uncertainty and to limit the risks for the patient by a selection of the optimal procedures. If we consider the contact between the doctor and the patient as a test by itself, we may say that GPs are expected to be sensitive while remaining specific enough, and that specialists have to be very specific, without neglecting some sensitivity.
In any scientific domain, professionals in the routine practice are frequently facing the problem of choices to be made in a context of uncertainty. In such situations, normative guidelines generally exist whose purpose is both to avoid inaction due to hesitation and to provide a consensual reference frame. When comparing medicine and law professions, one observes that such guidelines do effectively exist, but that they work in opposite directions. Briefly stated, one may say that for lawyers "it is preferable to free ten guilty persons than to put in jail a single innocent", but that for medicine " it is better to say to a healthy person that he/she is ill, than to miss a diagnosis in a diseased one".
Another way to say the same is : "for the law, anyone is supposed to be innocent as long as he/she has not been proven to be guilty". But, in medicine, it is the contrary: "a priori, the person doctors face is a patient, as long as it has not been demonstrated that he/she is healthy (free of any disease)".
Statistical considerations
Considering the statistical approach, there are two kinds of error. (table 1)
The first type error ( type 1or alpha error) consists in falsely rejecting a true hypothesis (false negative) and it is considered to be the most important. The second type error (beta error) inversely consists in accepting a false hypothesis (false positive) and it is considered as less important.
Here we deal with the hypothesis concerning the presence of the disease (M+), the alternative choice corresponds to the absence of the disease (M-); a positive test (T+) will lead to the "acceptance" of the hypothesis, when a negative test (T-) will lead to its rejection.. (see Table 2)
| False hypothesis M- |
True hypothesis M+ |
|
| Rejecting hypothesis T- |
1- ß | a (type 1 error) |
| No Rejecting hypothesis T+ |
ß (type 2 error) | 1-a |
| Total | 1 | 1 |
It is not evident, nor ineluctable, that the decision norms in medicine should always tend to control the type 1 error (Scheff, 1964) . The result of such an attitude is in fact to multiply irrational (unnecessary?) examinations, generating by itself an additional anxiety in many healthy "patients", as well as an explosion of the costs linked with ever more sophisticated diagnosis means (among which clinical biology testing).
In fact this commonly accepted attitude allows the doctor to exorcise his/her own anguish when facing uncertainty, but it confusedly mixes due care (commitment to quality in the process) and due results (commitment in the quality of the outcome). This permits to the doctor to preserve his/her image of good doctor … but at what price !!!
It clearly appears that the error medicine generally seeks to avoid above all when realising a test is the type 1 error : the purpose is to reduce the false negative tests. Because accepting a false negative decision effectively generates certain risks :
- - for the patient, in a first time by erroneously reinsuring him/her and consequently to differ a potential later consultation, in a second time, by letting him/her loose the confidence in the general medical system, and more particularly in his/her personal doctor;
- - for the doctor, who has to manage a diagnostic error and assume the subsequent guilt.
But risks linked with the second type error, i.e. with the false positive tests, are not less important, quite the contrary. Let us consider the whole chain of diagnostic, and sometimes therapeutic, procedures which will arise, with all possible iatrogenic consequences
A cross between illness and disease
Parodying the statistician four fold table, this one of the false positive and false negative, of the sensitivity and specificity, one can, crossing science and conscience, delimit four nebula. The term nebula is preferred, due to the fact that the limits between health and illness and health and disease are not clearly defined. But indeed, in the day to day practice the distinction are commonly used. In abscise, the science will show if disease is or not present. In ordinate, the patient feeling, well being and in harmony or sick and confused. (Table 3)
patient's feeling well being feeling sick feeling |
Disease evolution Absent --------------> Present |
|
| |
|
|
Table 3 : Four fields for the patient doctor encounter
We see that we can thus establish four fields which represent four different medical action areas. Indeed, if the patient is in good health or feels that way and that his doctor does not find anything wrong with him, it is the ideal state for developing a primary preventive attitude such as inoculation or Health Education.
The doctor however exercises all his art to discover an illness for the individual who feels in good health. This is the object of screenings and other secondary preventive examinations such as STD or cancer screening
If the patient and the doctor agree to accept the reality of the problem, we find ourselves in the curative field. Diabetes or high blood pressure, Lime disease or cardiopathy must of course be treated. A critical eye will then have to be cast on the medical activity itself and its complications be avoided. Moreover, these long course illnesses induce a new state of equilibrium which the doctor will try to promote. We then talk of rehabilitations. Reducing of complications and rehabilitations are the definition itself of tertiary prevention
One can hence see that one field remains, the one of the individual’s suffering, expressed and sometimes strongly felt but which does not meet the data of science or which brushes its limits. This field is the one of incredulity and often of scorn. This is where the ancestral fears appear and it is often the outcome of fears being medicalised . Hence the Monday morning invasions of cardiac feeling ill because of the Sunday television programme on cardiopathologies; the appearance of women who have become cancerophobics due to the messages on breast cancer; or the “normal” patients pathologised by a medical image at the limit of normality. The medical practice itself can thus, whatever the sector, primary, secondary or tertiary, generate serious troubles.
In order to control this tendency, auto-control (self-control ?) mechanisms must be defined which will carry the name of quaternary prevention.
The first three forms of prevention have been defined and published in the General Practice and Family Medicine Glossary by the WONCA International Classification Committee (Wicc, 1995). Based on the model of these definitions, the quaternary prevention would thus be :
Action taken to identify a patient or a population at risk of overmedicalisation, to protect them from invasive medical interventions and provide for them care procedures which are scientifically and medically acceptable.This definition has been adopted by the WONCA International Classification Committee during its Durham meeting in 1999 and would be published in the WONCA dictionary for general/family practice.(Bentzen, 2002)
The four definitions can be reintroduced in the same table with double entry (Table 4). The first three definitions are perfectly adapted to the field they occupy. Thus, the existence of a fourth, i.e. quaternary prevention, seems to be a matter of course.
It should be noted that the patient may create his own state of illness. He feels ill when in reality he is in good health. These troubles have always been known under the names of hypochondria or hysteria or nowadays somatoform troubles the limits of which are not very clear. Their prevalence is probably proportional to the number of available therapists. But if it is the doctor or medicine which are misleading and creating a sick person who in fact isn’t one, there is no name or definition for the “medical error from excess”. This is where Jules Romain meats Molière and Dr Knock makes the The Imaginary Invalid happy.
well being feeling sick feeling |
Absent ------------------------------------> Present |
|
Primary prevention
(e.g.immunization) |
Secondary prevention
(e.g. methods, screening, case finding and early diagnosis) |
|
Quaternary Prevention |
Tertiary prevention
(e.g. prevent complications of diabetes). Includes rehabilitation. |
|
I: The patient is not sick and you are in a health promotion process or in immunisation campaign,
II: The patient is not sick and you are screening for diseases,
III: Unfortunately you find the disease and now the patient knows that he is sick (but sometimes doesn't accept it).
IV: the last one, the fourth, is not the easiest, the patient feels sick and you find nothing or you were wrong in finding something. Health promotion, screening and medical activities could throw the patient into the fourth field
Medicine can be dangerous for your health
As already Ivan Illich wrote in 1976, medicine can be harmful for patients, and populations have to be protected against their own anxiety as well as again their carers' anxiety. Organising quaternary prevention therefore would consist in setting up the mechanisms able to control these perverse effects by establishing a feed-back control on medical activities (as in Quality assurance or medical ethics). This form of prevention will have to progressively become one of the leading challenges of the medicine of tomorrow, a new quality standard.
General practitioners and specialised doctors have indeed a fundamentally different view of the fourth cell. The specialist's competency is mostly appraised by his/her ability to shift patients into cell n° 3; this is in fact his/her role, on the basis of his/her specific training. But the risk is great to see the population jumping (or being pushed) into a medical "game" , the "Medical Flipper" according to Jean Carpentier.
At the basis of the healthcare pyramid, on the contrary, time is working for the GPs : longitudinal view, global approach and empathic confidence are their daily tools. Their task is to maintain for as long as possible their patients in the first cell (and even … what would health be in the absence of disease???), to use the second cell appropriately with the aim to shift in the third cell all those, and only those whose place is truly there ( neither more, neither less), and above all to avoid the fourth cell.
The optimal use of the four cells of the table is highly depending on a tight collaboration between GPs and specialists, seeking to reach in due time the optimal balance between sensitivity and specificity. Their respective interventions must for these reasons be selective and adequately planned in the time sequence.
patient's feeling well being feeling sick feeling |
Disease evolution Absent --------------> Present | |
|
Immunization |
| |
|
Ethics |
Cure | |
Table 5 : Content of the four fields for the patient doctor encounter
Consultation, a meeting between science and conscience is also a deal between patient and doctor anxiety. Quaternary prevention would raise the best way to protect the patient. Quality assurance and Medical ethics could help to control the process and the doctor's attitudes and beliefs in the three first fields. These four zones could also be useful in teaching and learning processes. Table 6 display a basic classification of medical activities really useful to organize resources in information field as experimented in an Internet site (Jamoulle, 2001)
Towards more complexity for GP/FM
- A slow progressing concept
- Quaternary prevention is born in 1985 during a (boring) lecture on Chi Square. (Jamoulle, 1986)
- In 1994, Hellström, in the same way, cross also the concept of illness and disease in a slightly different presentation. He describes four kind of perceptions between patient and doctor and between what is really sick and what is not. (Hellström, 1994)
- Presented at the Hong-Kong WONCA conference (Jamoulle 1995)
- Endorsed by the WICC at its Durham annual meeting in 1999
- Included in the international dictionary of GP/FM prepared by the WICC members under the rule of Niels Bentzen. (Bentzen, 2002)
- Interestingly and in a narrower sense, the term of Quaternary prevention has been used by a team of Israelian researchers to describe a quality assurance process (Gofrit 2000). Our concept encompasses this issue but our general meaning of quaternary prevention is much more larger
- Problem interaction in patient doctor encounter
- Generally in Europe more than one problem is addressed in an encounter (Lamberts 1993)
- Integrating prevention and curative role is one of the specificity of the GP/FM (xxx,nn)
- This led in reality to the necessity to structure the consultation following this new distribution of the four fields and the four prevention domain. In the table 5, a four problem encounter is shown, with a problem in each domain.
- New genetic could force to revise this concept
- New genetic borrows the frontier between well being and disease and between well being and illness
- The impact of new genetics could increase the number of worried well. A woman's risk of developing breast cancer based on her family history could not be properly assessed. There is a significant degree of variability between methods currently used to estimate breast cancer risk (Tischkowitz, 2000)
Table 6: The patient doctor encounter could encompasse problems in each field.
Here a 50 year old depressive smoking women asking a scan for her headache - A French general practitioner, Jean Carpentier (Carpentier, 1989) use an original way
to perceive the deep significance of the symptoms. A transparent plexiglas suitcase is divided by various transparent
partitions. Each partition bears one or two essential terms like family, work, dream, history, phantasm etc.(see fig 1) The first partition bears the term "Symptoms".
Thus looking through the suitcase, one can read the words " family, work, dream, history, phantasm ect" behind the first term symptom. This allows to understand patient's complaints in a different way. It is not a question of disease, nor symptom disease but only a way to exchange on the deep concern of the patient. Usually, this symbolic patient's view is quite difficult to understand by the doctor, but the patient, looking at the suitcase during an encounter understands often perfectly that family problems, working condition or personal history could explain the actual presenting symptoms.
 |
Fig 1 : The Symptom's suitcase (Carpentier, 1989)
Through Symptom , one can read transition [passage], signs[signes], roaming[errance], work[travail], unemployement[chomage],
familly[famille], neighbours[voisins], certainty[certitude], elsewhere[ailleurs],
dreams[rêves], phantasms[fantasmes],history[histoire]