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It's a scene that plays out thousands of times every day in doctors' offices across the country-the moment the doctor shifts from addressing the concerns that brought the patient into clinic to when he or she attempts to make sure everything else is going okay. Often it happens at the end of a sick visit, after working up an upper respiratory infection or back pain; sometimes it happens after following up a chronic medical problem such as high blood pressure or arthritis, and occasionally it happens under ideal circumstances, during an annual physical or routine wellness visit. It doesn't necessarily happen at the end of the visit; often it sneaks it's way into various points in the encounter - as when the doctor places his or her stethoscope over a patient's chest while evaluating the patient for knee pain.
What I'm referring to is so indistinct that it doesn't even have an universal name, but rather goes by many titles - preventive health, preventative health, preventive medicine, preventive care, health care maintenance, routine health care, routine check up, annual physical, and health and wellness - to name a few. But whatever you call it nearly everyone agrees how important it is. The health care reform debate was ripe with calls for more "health"-care not just "sick"-care, and one of the most welcome measures in the new health care legislation across both sides of the aisle are provisions to support it. Outside of Capitol Hall, from cereal boxes to magazine racks and celebrity doctors, messages about staying healthy are everywhere, as is the general belief that "an ounce of prevention is worth a pound of cure."
Preventive health care or preventive care, the terms I prefer to use, can be defined simply as the things a doctor does to keep a patient healthy. If you sprain your ankle and your doctor examines your foot, asks you questions about how you injured it, or refers you to physical therapy, that's not prevention. But if he or she also examines your heart and lungs, takes your blood pressure, or asks whether you smoke, that's prevention. From the form you fill out to the waiting room to the vital signs the nurse takes before you go in to see the doctor to the routine questions and physical exam maneuvers the doctor does during the visit, anything not related to what brought you into clinic or medical problems you are already known to have can be considered preventive health care.
Defined in this way, the standard office visit we are all familiar with presents myriad opportunities for prevention. While it may be considered a good thing that preventive care happens seamlessly in everyday medical practice, it is also occurring inconsistently. Study after study has shown us that doctors do not routinely provide the preventive health care that is proven to save lives and prevent disease. From vaccines and cancer screenings to counseling to lose weight and quit smoking, patients on average only get half the preventive care they should be getting. Only half.
Not all preventive health care is made equal. It surprises many people that just as there are medical studies to test out the latest chemotherapy drug or medical device, doctors also study approaches to keep patients healthy. From experiments to figure out which patients benefits most from aspirin and trials of new methods for colon cancer screening to whether doctors should counsel people about wearing seat belts, the medical literature is filled with scientific evidence about which preventive health services work and which don't, and the evidence base grows every day. Like robotic surgery and biologic therapies, preventive health care has a cutting edge too.
Some preventive care measures have been well-studied and are proven to keep patients healthy; others have been studied but not proven to work; and still others have not been studied or proven. In a time and resource-constrained world, it makes sense to start with those measures that are best studied and best proven. If we have time for more after that, then so be it.
It surprises people to find out where different common preventive care measures fall:
- Mammograms to screen for breast cancer - studied, proven; yearly breast exams by doctors to detect breast cancer - studied, not proven.
- Counseling smokers to quit smoking - studied, proven; counseling normal weight people about diet and exercise - studied, not proven.
- Blood pressure measurement every 1 to 2 years - studied, proven; annual physical exams - not studied, not proven.
- Cervical cancer screening (Pap smears) in women ages 21 to 65 - studied, proven; prostate cancer screening (PSA) in men at any age - studied, not proven.
- Routine blood work to check kidney or liver function, calcium levels, or thyroid function - studied, not proven; checking cholesterol levels in people at increased risk of heart disease, including all men over age 35 - studied, proven.
And yet, everyday in medicine we see patients that undergo "yearly blood work" but who aren't receiving the recommended annual flu vaccine, or men over age 50 who get a digital rectal exam to screen for prostate cancer but who haven't yet been told about colon cancer screening.
As a recent medical school graduate, I can tell you that at least part of the problem is that prevention is never really taught in medical school. In the first two years of medical school, we learn by the disease-to-symptom approach. We pour over heavy textbooks, turning from one disease to the next, committing to memory its pathophysiology, its pharmacology, and its associated symptoms. The second two years of medical school we go the other way. We learn how to take the symptoms patients come to clinic or the ER with and then deduce which diseases they have - the symptom-to-disease approach. But prevention isn't about symptoms. From a prevention point-of-view if the patient has symptoms then it's already too late. So where in the disease-to-symptom or symptom-to-disease approach does preventive health fit in?
As a medical researcher, another problem I've identified is that preventive health care has no home in academic medicine. The hallowed halls of teaching hospitals are divided by medical specialty - surgery, ob-gyn, psychiatry, pediatrics, internal medicine, etc. Internal medicine and pediatrics are further divided into cardiology, pulmonology, gastrointestinal, oncology, and so on. There is no such thing as a specializing in preventive medicine, and thus there is typically no dedicated department or division for prevention. The closest divisions we have are general pediatrics, general internal medicine, and family medicine; the fields which make up "primary care". While "preventive medicine" residencies exist, they are non-clinical training programs that are more based in public health than everyday practice and are few in number. This leaves prevention without a dedicated space of its own in medicine, without dedicated funding and dedicated practitioners, and still nameless.
As a primary care doctor, another problem is in the delivery of preventive health care. Expert guidelines about preventive health care exist but are often conflicting. Remember the hailstorm last year over the mammography guidelines released by the US Preventive Services Task Force (USPSTF)? When one expert organization tells doctors to start screening for breast cancer by age 50, yet another recommends routine mammography at age 40, doctors and patients are left at a loss for what to do. Even when the guidelines are clear, implementing them can be difficult. Primary care doctors work in hurried practices that use outdated paper charts or meaning-less use health IT and are not reimbursed for the extra time required to coordinate care and counsel patients about preventive health. Patients often refuse preventive health services such as the flu shot citing concerns that the vaccine itself will make them sick. And even if the doctor has time to talk about preventive care, and the patient agrees, it doesn't mean his or her insurance company will. The Centers for Disease Control and Prevention (CDC) recommends the shingles vaccine for all adults over age 60, yet insurance coverage has lagged behind.
Clearly such a multifold problem will require a multipronged solution. Medical students and residents need more formal training in prevention. Preventive health care needs more funding and support from the government and academic medical centers. Doctors need better tools and more support to deliver prevention. We all agree that prevention is important and the delivery of preventive health care needs fixing. But first thing first - let's get preventive health care out in the open. Let's recognize when it is happening as it should and when it isn't. Let's be clear about what we mean when we talk about prevention. And by all means let's give it a name.
Copyright Shantanu Nundy, M.D.
If you enjoyed this post, please visit Dr. Nundy's web site BeyondApples or read his book, Stay Healthy At Every Age.
