Download Teaching Preventive Medicine and Health Maintenance

Teaching Preventive Medicine and Health Maintenance
Robert H. Fletcher, MD, and Suzanne W. Fletcher, MD
• Preventive health care is an important part of the
practice of internal medicine but is poorly taught and
practiced in most residencies. A successful curriculum
would impart knowledge of the preventive health care
guidelines recommended by expert groups; provide
opportunities for residents to understand the conceptual basis of preventive care; expose residents to
clinical faculty with positive attitudes toward prevention; help residents to learn skills in physical examination, screening tests, and counseling in behavioral
modification relevant to prevention; and provide a practice environment in which high-quality preventive
health care is possible. All of the skills can be learned
as other aspects of medicine are now learned—under
the guidance of capable and respected faculty teaching
at the bedside, in the clinics, and during ward rounds
and conferences.
Annals of Internal Medicine. 1992;116(12 pt 2):1094-1098.
From the American College of Physicians, Philadelphia, Pennsylvania. For current author addresses, see end of text.
x reventive health care is an important part of the practice of medicine. Four percent of internists' encounters
with patients are for periodic health examinations (1),
with a much larger proportion of internists' time being
spent on all other aspects of preventive care. Preventive
care is an issue for all internists—not only for general
internists but also for many subspecialists who give
comprehensive care, which includes preventive care, to
some of their patients (2). Subspecialists in infectious
diseases, for example, spend more time on preventive
services than do general internists (1).
If residency is to prepare internists for the practice of
medicine, and prevention is an important part of that
practice, then preventive health care should be an important aspect of residency training. Unfortunately, it is
not. Residents spend little of their time giving preventive care, and they and their faculty have a poor understanding of the concepts on which preventive care is
based. Only a small proportion of patients under residents' care in ostensibly excellent programs receive basic preventive services. In a national sample of teaching
medical clinics, only 19% of eligible patients received a
pneumococcal vaccine, and only 30% received at least
one vaccination for influenza (3).
Thus, a double standard exists. Residency programs
tolerate disregard for well-established, scientifically
based guidelines for prevention but expect uniformly
high performance in care of the sick. The difference
between preventive and illness care, however, is artificial and can and should be removed.
A successful curriculum in preventive health care will
improve the knowledge, attitudes, and skills of residents and the organization in which they practice preventive care (4).
Knowledge
Guidelines
Few areas of medicine have received as much evidence-based scrutiny as preventive health care. Several
expert groups have reviewed the tests and procedures
that might be useful for preventing diseases in people
without symptoms and have made recommendations.
The most rigorous recommendations come from the Canadian Task Force on the Periodic Health Examination
(5), the U.S. Preventive Services Task Force (6), and
the American College of Physicians (7). These groups
suggest guidelines for what should be done for patients,
according to the patients' age and sex, during periodic
health examinations. Residents should know these recommendations as well as they know the latest treatments for septic shock or the diagnostic tests for multiple myeloma.
The expert groups, for the most part, agree in their
recommendations. Disagreement is mostly about the
frequency of services and the age at which these services should be provided (7). Nevertheless, some recommendations are controversial. For example, some
groups recommend that breast cancer screening by clinical examination and mammography begin at 50 years of
age, whereas other groups recommend that screening
begin earlier. These disagreements are not unexpected
and not out of proportion to other controversies in
medicine, such as whether tissue plasminogen activator
is safer and more effective than streptokinase for acute
myocardial infarction. Disagreements about preventive
services offer a wonderful opportunity for residents to
learn about the rules of scientific evidence and about
how vested interests and the social and economic environment of medicine color the interpretation of data.
Concepts
A basic tenet of medical education is that physicians
should know not only what to do, but why they should
do it; that is, they should understand the conceptual
basis for their work. Traditionally, physicians have
been expected to know how clinical practice is
grounded in basic sciences such as anatomy, physiology, and biochemistry. They should know, for example,
why a mediastinal mass can cause hoarseness, why
hyperglycemia causes diuresis, and why alcohol use
causes tolerance for other drugs.
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The elements of the periodic health examination are
no less amenable to scientific justification. The evidence, however, comes not so much from the traditional basic sciences of medicine as from epidemiology
as it applies to clinical practice—that is, "clinical epidemiology" (8). The methods and perspective of clinical
epidemiology are the basis for guidelines for secondary
prevention (early detection and treatment), which include the burden of suffering, measured by the morbidity and mortality (and cost) of disease in the population
as a whole; the accuracy and feasibility of diagnostic
tests; and the effectiveness of treatment at an earlier
stage, relative to the stage when the disease would
ordinarily be found.
Clinical epidemiology can help explain why increased
survival from the time of diagnosis (for example, for
cancer found early by screening) does not necessarily
mean a net gain in life expectancy has occurred (leadtime bias); why an initial screening program may have
higher yield than later cycles and may discover tumors
with a better prognosis (length-time bias); and why volunteers may have a better prognosis than patients who
are not volunteers (compliance bias) (8). Misunderstanding about these concepts is widespread at all levels
of academe and is the root of much confusion about the
effectiveness of some screening tests, such as the fecal
occult blood test or sigmoidoscopy for colorectal cancer. This confusion may explain why physicians in practice (9) and residents (3) still fail to do many tests for
which there is compelling evidence of benefit and, conversely, do many tests for which there is not.
Current textbooks and journal articles, written specifically for clinicians, set out the scientific basis for critical appraisal of clinical research, including studies of
preventive health care. These publications can provide
the foundation for discussions of preventive care on
ward rounds, in clinics, and at journal clubs. Although
these concepts are gaining wider currency in medicine,
many medical schools do not include them in their
formal curricula, thereby requiring residency programs
to begin instruction at a basic level.
quit smoking, and 87% felt that they should do so. Only
54% of residents felt confident in their ability to counsel
patients, and only 31% felt that they were successful
(10).
To acquire positive attitudes toward preventive health
care, residents must be exposed to role models from
within their subculture (the residency program and its
faculty) who are enthusiastic about and expert in prevention. Doctors are notoriously skeptical of outsiders,
and residents not the least among them: They do not
want to learn about prevention from people outside
their circle of colleagues. Moreover, if experts in preventive health care have to be imported—for example,
from a school of public health or a department of community and preventive medicine—residents will not perceive prevention as an integral part of internal medicine.
Role models in clinical preventive medicine are likely
to make up only a small proportion of medical faculties
in the foreseeable future. If the other faculty members
care little for prevention, then the effects of the enthusiasts are likely to be undone. So the faculty as a whole
must acquire positive attitudes and behaviors. Because
most of the faculty for the next decade is already in
place, reorientation of their thinking will be necessary.
Attitudes
Physical examination skills are traditionally taught in
medical school. One could argue that during the already
overfilled hours of residency, training beyond what residents naturally accrue from working up patients is not
necessary. In any case, little effort or time is spent
formally perfecting physical examination skills during
residency.
Evidence exists that at least one physical examination
skill that is important in disease prevention is not mastered by internal medicine residents. A universally recommended part of preventive care is the search for
early breast cancer with a yearly breast examination in
women over 40 years of age. In the context of prevention, physicians need to be able to detect small cancerous lesions (sensitivity) and differentiate these from the
normal, lumpy, glandular and fibronodular tissue in the
breast (specificity). Many medical students receive little
training in breast examination (11). Residents have reported that they do not think the breast examination is
well taught in medical school, that they feel they need
more training, and that they do not feel confident in
Modern medicine comes from a long tradition of
treating the sick. Internal medicine's heroes from the
past—Sydenham, Charcot, and Osier—were great diagnosticians. Current heroes are scientists who elucidate
the mechanisms of disease at the molecular level. Local
heroes, the clinical faculty, are selected and rewarded
for work far removed from preventive health care. Indeed, clinical faculty the world over have tended to
look down on preventive medicine specialists in departments of community and preventive medicine. Residents are immersed in this subculture and acquire their
attitudes from it, as well as from the ideals they brought
to medicine and from the attitudes of society as a
whole.
Studies of residents' attitudes toward preventive care
consistently show a gap between what they feel they
should do and what they believe they can do, given the
hard realities of residency training. In one study, 98%
of residents felt responsible for counseling patients to
Skills
Health promotion and disease prevention activities
recommended by expert groups (7) fall into four major
categories: physical examinations, laboratory tests, immunizations, and behavioral counseling. Residents need
to develop three kinds of skills: performing specific
components of the physical examination, conducting
screening tests (Papanicolaou smears and sigmoidoscopy), and counseling patients to adopt healthful behaviors. Although residents may order laboratory tests and
immunizations for preventive purposes, they rarely perform them.
Physical Examination and Screening Tests
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their ability to detect breast lumps. Measurement of
residents' ability to detect breast lumps and of their
examination techniques suggests they are correct. In
one study, residents detected only about half of the
simulated breast lumps in manufactured silicone breast
models, using many different techniques (11). In another study, residents rushed the examination, spending
on average less than 1 minute per breast (12). A randomized, controlled trial of training of internal medicine
residents on breast models found that detection of
lumps could be improved and breast examination technique could be standardized (13).
Fewer studies have evaluated how well internal medicine residents do Papanicolaou smears and sigmoidoscopies and how these skills could be improved. In a
recent analysis of the data from the 1985 National Ambulatory Medical Care Survey, internists were half as
likely as gynecologists to include a Papanicolaou smear
when doing a general physical examination (14). Another study found that Papanicolaou smears obtained by
internists in a community hospital were more likely to
be technically inadequate than those obtained by gynecologists (38% and 21% of smears, respectively) (15).
Smears obtained by residents were more likely to be
inadequate than those obtained by faculty.
Although some expert groups recommend periodic
sigmoidoscopy for colon cancer screening (7), and the
American College of Physicians has published guidelines for clinical competence in the use of flexible sigmoidoscopy for screening purposes, little information
has been obtained about training internal medicine residents in sigmoidoscopy skills. One study (16) found
that residents needed 24 to 30 supervised examinations
with flexible sigmoidoscopy before being judged competent.
Thus, available data suggest that internal medicine
residents lack the physical examination skills needed for
preventive health care, even for examinations considered to be part of the classic internal medicine activities. The manual skills required to be an excellent internist need more attention during residency training.
Behavioral Counseling
Behavioral modification is an important part of health
promotion and disease prevention. Smoking cessation,
diet modification, and regular exercise are just a few of
the healthful behaviors recommended by expert groups.
Physicians clearly should play a role in helping their
patients adopt these behaviors. Traditionally, however,
physicians have received little instruction, in medical
school or residency, in how to become effective behavioral counselors. Not surprisingly, residents' behavioral
counseling skills have been found to be poor when
formally tested (10).
Several studies over the past decade have shown how
physicians can improve their smoking cessation counseling skills; more recently, studies have evaluated the
effectiveness of teaching smoking cessation counseling
techniques in residency programs (17). These study results are clear: Teaching residents the counseling skills
is possible and feasible; more patients give up smoking
after being counseled by trained residents; and residents
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report positive reactions to the instruction. Less is
known about effective physician counseling for other
health behaviors, and therefore little evaluation research has been published on how to teach internal
medicine residents these other skills.
Behavioral counseling is a communication skill that is
needed for all aspects of the practice of medicine, not
just for prevention (18). Internists work daily to improve many types of patient behavior; they try to ensure that their patients take their prescribed medication,
keep their appointments, and undergo necessary invasive tests and treatments. As the practice of internal
medicine increasingly involves the management of
chronic conditions over time, the patients become more
important as partners in determining the outcomes of
their care. Residents need education, both theoretical
and practical, to learn how to effectively counsel patients, whether for smoking cessation, changing a diet,
taking complicated regimens of medications, or understanding the need for and options about cardiac catheterization.
Organizing Residency Practice for Prevention
If residents are to develop the knowledge, attitudes,
and skills necessary to deliver excellent preventive
health care, they must be able to practice prevention in
the care of their own patients. Residents practice preventive care primarily in their continuity clinics. Many
studies have documented that the level of preventive
care practice is quite low in these settings (3, 19); that
performance increases when physicians are prompted,
either manually or by computer (20, 21); and that when
prompting stops, performance falls (20).
Difficulty in sustaining performance without assistance is not surprising, given the nature of preventive
services. Recommendations vary by the age, gender,
and clinical characteristics of each patient; the frequency of recommended procedures differs from one to
another; and preventive activities are usually incorporated into regular patient visits, when the physician is
dealing with active, often multiple, medical problems.
Keeping in mind exactly what preventive procedures
should be done at a given time for a given patient is
difficult. Thus, a simple prompting system needs to be
put in place. The effect of prompting does not appear to
diminish over time (22), and residents indicate that they
like the reminders (23).
Computerized prompting systems for health maintenance incorporate features that can be especially useful
for resident practices. Computerization makes it possible to review overall performance, both for individual
residents and for the practice as a whole. These features could promote a new approach to resident learning and practice organization based on patterns of care
rather than on isolated events. With a computerized
prompting system, such as the one in place at the University of North Carolina, residents can review their
individual performance for their entire panel of patients
and compare their performance with that of their colleagues.
Figure 1 shows that residents vary greatly in the
percent of their eligible patients they enrolled in a
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Figure 1. Percent of patients in continuing care who were enrolled in the health maintenance program by residents in the
medical polyclinic, North Carolina Memorial Hospital, in 1988.
health maintenance prompting system. Preceptors can
use this information when discussing with residents not
only their approach to a given patient but also their
practice patterns for their entire panel of patients. At
the University of North Carolina, the system was used
by the residency program director to identify for special
commendation residents providing exemplary preventive medical care. Computerized prompting systems can
also be used to examine practice-wide preventive care.
Responses to new initiatives to improve preventive care
in general and for specific preventive services can be
monitored.
Residents can learn about and practice prevention in
subspecialty clinics as well as in their own clinics. In
many teaching hospitals, there are separate clinics for
prevention of breast cancer, colon cancer, osteoporosis,
lipid disorders, heart disease, and so forth. Categorical
prevention programs certainly have a patient-care role,
especially for the care of high-risk patients. They can
also play a useful role in residents' education for prevention. The categorical approach, however, is too inefficient and fragmented to be the main method by
which preventive care is either delivered or taught (24).
Relatively little attention has been paid to the effect
of preventive medicine on inpatient services, but in
some circumstances there might be high returns. For
example, most patients who develop influenza have
been hospitalized in the previous year (25); perhaps
residents should be taught to consider ordering an influenza vaccination when discharging patients.
already well taught, well organized, and successfully
performed in pockets of excellence throughout the
country.
The elements of success are relatively straightforward
and are compatible with more traditional aspects of the
medical curriculum and how these aspects are learned.
Residents should know the guidelines for periodic
health examinations, just as they know differential diagnoses and antibiotic doses. They should consider clinical epidemiology an additional basic science for clinical
medicine and understand its concepts as they do more
traditional ones, such as anatomy and biochemistry.
Residents should develop skills in doing screening tests
such as breast examination and sigmoidoscopy, just as
they do for lumbar punctures and central venous lines.
They should also develop skills in counseling about
behavior change, which will stand them in good stead
for curative and palliative care as well. Finally, residents should work in settings where preventive health
care is held to a high standard, and where it can be
done well, just as the wards and intensive care units are
settings where curative and palliative medicine can be
done well.
All of this knowledge can be taught just as medicine
is now taught—at the bedside, in the clinics, and during
rounds and conferences. Some of the faculty must be
expert and enthusiastic, and their influence must be
reinforced by the rest of the faculty, who may be less
committed to preventive care. Because the curriculum
is already full, preventive medicine may need to be
incorporated at the expense of some other issues that
are less central to the practice of internal medicine;
many of the lessons learned in preventive care, however, are also useful for other aspects of patient care.
A missing ingredient has been the will to incorporate
preventive medicine in the curriculum and to do it well.
Residents and their program directors look to traditional
sources of authority in medicine for leadership. Signs of
change are appearing. Major textbooks of internal medicine now contain sections on health promotion and
disease prevention. The American Board of Internal
Medicine is including in its examinations more questions about preventive medicine, as is the American
College of Physicians in its Medical Knowledge SelfAssessment Program. The Residency Review Committee in Internal Medicine could affect reform by incorporating requirements for prevention education in
revisions of its requirements for internal medicine residencies. Most important, the professors of medicine
can, if they take the lead in this matter, have great
influence.
Requests for Reprints: Robert H. Fletcher, MD, American College of
Physicians, Independence Mall West, Sixth Street at Race, Philadelphia, PA 19106-1572.
Current Author Addresses: Drs. Fletcher and Fletcher: American College of Physicians, Independence Mall West, Sixth Street at Race,
Philadelphia, PA 19106-1572.
A New Curriculum
Clinical preventive medicine is not uncharted territory. Model curricula in preventive care have been developed on a national scale (26), for local programs (27),
and for individual diseases. Preventive health care is
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