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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. 1094 © 1992 American College of Physicians Downloaded From: http://annals.org/ by a Penn State University Hershey User on 09/16/2016 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 15 June 1992 • Annals of Internal Medicine • Volume 116 • Number 12 (Part 2) 1095 Downloaded From: http://annals.org/ by a Penn State University Hershey User on 09/16/2016 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 1096 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 15 June 1992 • Annals of Internal Medicine • Volume 116 • Number 12 (Part 2) Downloaded From: http://annals.org/ by a Penn State University Hershey User on 09/16/2016 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 References 1. A new survey on access to medical care (Special Report No. 1). Princeton, New Jersey: Robert Wood Johnson Foundation; 1978. 2. Aiken LH, Lewis CE, Craig J, Mendenhall RC, Blendon RJ, Rogers DE. The contribution of specialists to the delivery of primary care. N Engl J Med. 1979;300:1363-70. 15 June 1992 • Annals of Internal Medicine Downloaded From: http://annals.org/ by a Penn State University Hershey User on 09/16/2016 • Volume 116 • Number 12 (Part 2) 1097 3. Kosecoff J, Fink A, Brook RH, Da vies AR, Goldberg G, Linn LS, et al. General medical care and the education of internists in university hospitals: an evaluation of the Teaching Hospital General Medicine Group Practice Program. Ann Intern Med. 1985;102:250-7. 4. Preventive Health Care Committee, Society for Research and Education in Primary Care Internal Medicine. Preventive medicine in general internal medicine residency training. Ann Intern Med. 1985; 102:859-61. 5. Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J. 1979;121:1193-254. 6. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions. Report of the U.S. Preventive Services Task Force. Baltimore: Williams and Wilkins; 1989. 7. Hayward RS, Steinberg EP, Ford DE, Roizen MF, Roach KW. Preventive care guidelines: 1991. Ann Intern Med. 1991;114:758-83. 8. Fletcher RH, Fletcher SW, Wagner EH. Clinical Epidemiology: The Essentials. 2nd ed. Baltimore: Williams and Wilkins; 1988. 9. Romm FJ, Fletcher SW, Hulka BS. The periodic health examination: comparison of recommendations and internists' performance. South Med J. 1981;74:265-71. 10. Kenney RD, Lyles MF, Turner RC, White ST, Gonzalez JJ, Irons TG, et al. Smoking cessation counseling by resident physicians in internal medicine, family practice, and pediatrics. Arch Intern Med. 1988;148:2469-73. 11. Fletcher SW, O'Malley MS, Bunce LA. Physicians' abilities to detect lumps in silicone breast models. JAMA. 1985;253:2224-8. 12. Kahn KL, Goldberg RJ. Screening for breast cancer in the ambulatory setting [Abstract]. Clin Res. 1984;32:649A. 13. Campbell HS, Fletcher SW, Pilgrim CA, Morgan TM, Lin S. Improving physicians' and nurses' clinical breast examination: a randomized controlled trial. Am J Prev Med. 1991;7:1-8. 14. Bartman BA, Weiss KB. Women's health care in the ambulatory setting [Abstract]. Clin Res. 1991;39:595A. 15. Kaatz S, McCarthy B, Ward R, Schiffman R, Totzkay CM, Young M. Differences in Pap smear adequacy obtained by internists and gynecologists in community settings [Abstract]. Clin Res. 1991 ;39: 602A. 1098 16. Hawes R, Lehman GA, Hast J, O'Connor KW, Crabb DW, Lui A, et al. Training resident physicians in fiberoptic sigmoidoscopy: how many supervised examinations are required to achieve competence? Am J Med. 1986;80:465-70. 17. Ockene JK, Quirk ME, Goldberg RJ, Kristeller JL, Donnelly G, Kalan KL, et al. A residents' training program for the development of smoking intervention skills. Arch Intern Med. 1988;148:1039-45. 18. Strecher VJ, Becker MH, Clark NM, Prasada-Rao P. Using patients' descriptions of alcohol consumption, diet, medication compliance, and cigarette smoking: the validity of self-reports in research and practice. J Gen Intern Med. 1989;4:160-6. 19. McPhee SJ, Richard RJ, Solkowitz SN. Performance of cancer screening in a university general internal medicine practice: comparison with the 1980 American Cancer Society Guidelines. J Gen Intern Med. 1986;1:275-81. 20. McDonald CJ, Hui SL, Smith DM, Tierney WM, Cohen SJ, Weinberger M, et al. Reminders to physicians from an introspective computer medical record: a two-year randomized trial. Ann Intern Med. 1984;100:130-8. 21. McDonald CJ. Protocol-based computer reminders, the quality of care and the nonperfectability of man. N Engl J Med. 1976;295: 1351-5. 22. Harris RP, O'Malley MS, Fletcher SW, Knight BP. Prompting physicians for preventive procedures: a five-year study of manual and computer reminders. Am J Prev Med. 1990;6:145-52. 23. Knight BP, O'Malley MS, Fletcher SW. Physician acceptance of a computerized health maintenance prompting program. Am J Prev Med. 1987;3:19-24. 24. Fletcher RH, Fletcher SW. Health promotion/disease prevention: a categorical approach? [Editorial]. J Gen Intern Med. 1986;1:340-2. 25. Fedson DS. Influenza prevention and control: past practices and future prospects. Am J Med. 1987;82:42-7. 26. Barker WH, ed. Teaching Preventive Medicine in Primary Care. New York:Springer; 1983. 27. Jensen NM, Dirkx JM. A Curriculum for Internal Medicine Residency: The University of Wisconsin Program. Philadelphia: American College of Physicians; 1989. 15 June 1992 • Annals of Internal Medicine • Volume 116 • Number 12 (Part 2) Downloaded From: http://annals.org/ by a Penn State University Hershey User on 09/16/2016