Preventative Medicine?

[Guest misagh]

Hello all,

 

Do any of the schools in Canada offer a specialty that is similar to what some countries term "Preventative Medicine"? I wish I knew more about what this specialty entails... I know that in things like family medicine there is an aspect of preventative medicine. But, I'm wondering if PM can be its own thing?

 

Thanks in advance...

[Guest Lactic Folly]

I think that in the US, preventive medicine includes things like public health, occupational medicine, and aerospace medicine..

 

In Canada, community medicine is its own specialty, as is occupational medicine. Training is also available in aerospace medicine but I don't know the path to take for that. Community medicine sounds closer to what you're describing.

[Guest Ian Wong]

Community medicine is sort of an epidemiological specialty. ie. not really a Dr-patient type relationship, but maybe a Dr.-city, or Dr.-Country relationship. It can involve a lot of decisions regarding health policy and such, in other words, things like mechanisms to prevent another Walkerton contaminated water fiasco, or deciding when/which vaccinations should be given to the population, etc. It's preventative in nature, but on a wider global scale.

 

If you are referring to the type of preventative medicine that a physician might do on a 1-on-1 basis with a patient (ie. mechanisms to quit smoking, dietary suggestions, advice on exercise regimes, etc), as far as I know, there is no residency nor dedicated specialty for that type of training. You're just supposed to pick that stuff up along the way. A bit of a shame, really.

 

Ian

[Guest tirisa]

In terms of specializations, I think that much of what you have been describing falls under the specialty of Family Medicine... family docs have the opportunity (and it's one of the principles of FM) to establish one-on-one relationships with their patients that continue throughout their lifetime and extend to the family. This gives them the ability and opportunity to practice preventive medicine, tailored to the needs of each patient (smoking cessation, exercise, or diet advice for others, regular cholesterol testing for others with family history of CVD, for example).

 

I agree that community medicine or population health falls under epidemiology. And that's a whole other exciting field to discuss.

 

Anyway, I'd be interested to hear what others think about the family med- preventative med link.

 

Cheers,

T

[Guest jmh2005]

Tirisa,

 

I totally agree with what you have said...this was my whole reason for going into medicine and even used this extensively in my application! As a therapist, I saw people only after they became ill, injured, disabled and much of what I saw COULD have been prevented!!

 

I think Family Medicine physicians are the best to practice this type of medicine, however I think due to time and money, many forget about this very important aspect of medicine (not all, but some)!

 

J

[Guest DrSahsi]

I'd argue that preventative medical strategies, particularly as part of periodic health examination, are one of the cornerstones of family medicine. Ian argues that you are merely expected to pick up on these things along the way, and this simply is not the case. Topics such as smoking cessation, dietary counselling, prescribing exercise, and other such lifestyle management schemes were a big part of what I covered every day in my office during my FM residency, and I was definitely reading up on those topics when preparing for my licensing exam.

 

The difficulty with employing many of these strategies is that the focus of much of medicine is on fixing problems once they occur, as opposed to keeping them from happening in the first place. "Upstream" vs. "downstream" thinking. It's not just the physicians who can be biased to think this way... as I've discovered by the number of patients I've had to strongarm into coming in for their periodic health exams. When people deem themselves "healthy" they're *VERY* hard to get into the office.

 

jmh's point, though most physicians don't like to acknowledge it, is entirely valid. The pressure to pump patients through a busy office can be overwhelming. It can be hard in practice to remember what you're taught in residency about slipping a little health maintainance topic into the short, easy visits. Instead you refill that Rx and run to the next room. Perhaps the move away from fee-for-service family practices to a rostered model will help with this. Who knows?

 

- Rupinder

[Guest misagh]

Thank you all for your wonderful comments!

[Guest Ian Wong]

Rupinder,

 

Thanks for the heads-up. My impressions were from a few interactions with Family Med residents, usually when they were off-service. During those times, they were busy learning and refining the general medicine (and assoc. scut) of that particular specialty. As a result, I don't speak from direct experience as you do.

 

What I had hoped to convey was that in my limited experience, there was never a didactic time during rotations when you were told: "Here's the best strategy for optimizing a patient's household post-stroke to minimize the chances for a future fall", or "here's some tips to teach your patients how to maintain compliance on an exercise regime", or "here's some exposure to all the alternative treatments that your patient might be taking so that you can at least have a meaningful conversation about their pros and cons."

 

It just seemed that you'd learn about that stuff through self-guided learning (ie. you go online and read about feverfew on your own time), or that it might come up during a random encounter with your preceptor or patient. But because I don't think it's a didactic thing across residency programs, I don't believe that any two graduates from a Family medicine program could be expected to have the same level of exposure.

 

I do think family docs are the best placed to practice preventative care, and it's undoubtedly the most important part of caring for the average healthy patient to keep them that way; I just think that acquiring that knowledge is more self-directed than it should be for such an important topic. Just my impression as a non-family doc guy.

 

I agree that in busy times it's tough to get that preventative emphasis in, but that's a whole other can of worms!

 

Ian

[Guest macMDstudent]

Just to add another viewpoint as a former chiropractor who tried diligently for my years in practice to try to give people a good plan for preventing recurrance of their problem by instructing them how to do a few minutes of simple daily exercises. I know that compliance was really low, despite how energetically the patient said they would do the exercises. Of course the end result was the same problem recurring and more missed days of pain and days off work/school for the patient. It's frustrating as a practitioner to keep banging your head agains a wall. We are not the patient's keeper. I do think we have an obligation as a profession and practitioners to present the information in a clear, understandable way for how people can take better care of themselves. But when people keep coming back with the same problem and don't do the simple things that our training and experience tells us will help them, you have to let them choose their own path.

 

Before people jump on me and say, "Well, you were just a chiropractor. People will listen to their MD." I know the same goes on in medicine all the time. I know the docs who Rupinder did his Family Medicince community placement with. These are excellent docs running a good practice with over 10 years experience, and they tell me their patient's compliance with treatment as well as prevention strategies is poor. In fact, one of those docs once told me in frustration, "I had a patient tell me that they stopped their medication because a bag boy at the supermarket told them of something he heard on TV that would work better." He was distraught that his opinion was worth less to his patient than some second hand infomercial @#%$. This is not a reflection of the doc, he is amazing and a faculty member at Mac. I have heard the same thing from lots of docs who try hard to integrate prevention into their care. This does not mean that we should stop telling people not to smoke, but on the other hand we have to recognize people don't always change behaviour very easily. It is also a reflection of the society we live in that we are inundated with information, and the MD is just one more source of information.

 

Of course, having motivated patients that want to make a change makes all the difference in the world, and those people do make the changes you suggest and are a real plesure to work with. But I would suggest that those patients are the minority; but are also most fun to work with. So preventative care can be frustrating with some patients and incredibly rewarding with others. But the patients set the tone and will only change when they are ready to change, in my opinion.

 

As far as Family Health Networks and rostering patients being a better environment to provide preventative health care than fee-for-service, only time well tell. Again, knowing many family docs that practice both ways and talking to them extensively about it, it hasn't really changed their practice style very much at all, but has given them a better schedule and rewards them better for what they were doing before anyway (e.g. hospital admissions, nursing home care, bonuses for house calls etc.). They are all still crazy-busy on a daily basis.