Permanente Institutes of Preventive Medicine |
J Felitti, MD
Looking Back, and Forward
I am pleased
and honored to be Guest Editor of this special issue of The Permanente
Journal. In my 36th year of association with Kaiser Permanente (KP),
no one is more surprised than I that I have spent the majority of that
time in Preventive Medicine, far from Infectious Diseases, where I started.
While physicians readily give lip service to Preventive Medicine, it
is often considered a dull, somewhat ineffectual field dealing with
immunization schedules, cautionary statements, and a handful of unchanging
public health problems. These certainly do not attract physicians like
the drama of acute care medicine and surgery. Further, the most basic
causes of many public health problems are truly complex, difficult to
understand, and often inadequately studied when they involve behavioral
issues--as they frequently do.
the general lack of attention to Preventive Medicine provides an opportunity
to develop and test new ideas in this field, especially in a large organization
like KP. This issue of The Permanente Journal deals with just
such new ideas. If we are serious about preventing disease, we ought
to think carefully about why people become ill. What is illness?
How does illness relate to disease? These are not easy questions, and
our teachers and mentors didn't prepare us for them in medical school
and residency. In candid moments, many of us admit to being unprepared
for much of what walks into the office during our first several years
A Pathway Through this
Issue "A General Theory of Love"
pathway through this special issue on Preventive Medicine starts with
the book review of A General Theory of Love.
It is the lack of love, and our various responses to this lack, that
produces much illness and a significant portion of the common chronic
diseases. In the Fall issue, the book review of Growing
Up Fast illustrated the effects of lack of love in the context
of teenage pregnancy and its biomedical, psychological, and social complications.1
In this issue, Gregorio Saccone, MD's review of Dry
gives us insight into the underpinnings of alcoholism--useful knowledge
if one is serious about understanding its prevention. Crossing
the BLVD looks into the lives of immigrants--physicians and
patients--What do we know of vastly different cultures, torture, exotic
diseases? The popularity of Dr Chopra's books illustrates the widespread
desire of patients for a humanistic understanding of themselves.
Relation of ACE to Job
We touched on the theme of the emotional underpinnings of illness and
disease in a prior issue with an overview article about the Adverse
Childhood Experiences (ACE) Study.2 The ACE Study showed
in a 17,000-patient KP cohort of middle-aged adults the relation of
eight categories of adverse childhood experience to some of the most
common public health problems in the country: depression and suicidality;
obesity and its consequences of Type 2 diabetes and hyperlipidemia;
smoking and COPD; alcoholism; intravenous drug use and its association
with chronic hepatitis; etc. The current issue's article
from the CDC by Robert F Anda, MD, MS, and Vladimir I Fleisher,
MD, PhD; et al on the relation of adverse childhood experiences to job
performance and occupational health extends this work and is a good
illustration of the complexity of some of the problems faced in Primary
Care and Occupational Medicine, especially when the origins of preventable
problems are hidden by time, shame, secrecy, and social taboo.
Infant Feeding as Primary
In our collaboration with the CDC, the question arose repeatedly of
where and when to intervene for preventing either adverse experiences
in childhood or their later consequences. While treating middle-aged
adults is necessary and important for learning, it is clear on a population
basis that primary prevention is our only realistic option. However,
primary prevention, aside from immunization, is notably difficult; in
many instances, one would have to begin during infancy, if not pregnancy.
Charles W Slaughter, MPH, RD, does that in his unusual article
on infant feeding. "Hungry for Love" looks at primary
prevention through different eyes.
From Hawaii, pediatrician David M N Paperny, MD, describes a approach
to preventive screening in that difficult population: adolescents.
If you are in Hawaii, visit him and see first-hand what his program
looks like. He has put to use, on interactive DVD, ideas for engaging
teens meaningfully that the rest of us would never have imagined. He
has a "best practice" that has been overlooked. Mary
Shannon's Soul of the Healer article is about what happens when
common problems like childhood sexual abuse are not sought out
for recognition. This theme is further expanded by Dr
Ritterman's sensitive appraisal of the psychosocial determinants
Transplantation as Preventive
Traditional biomedicine clearly has a role in Preventive Medicine; after
all, that is where Preventive Medicine started. The article by Gillian
M Beattie, BSc and Alberto Hayek, MD, on the stem
cell cure of Type 1 diabetes is exemplary; additional complications
of diabetes are totally prevented by this remarkable approach. Surprisingly,
some existing complications like diabetic neuropathy are actually reversible
with transplantation. Their article comes from one of the few stem cell
laboratories in the country. They show that solving what appears to
be a pure biomedical problem is not only biologically difficult but
is politically difficult as well.
"Hemochromatosis Update" summarizes
what we have learned in the KP San Diego Department of Preventive Medicine
by taking a purely biomedical approach to this highly prevalent mutation
but less common disease. The article contains an interesting twist showing
the need for what George Engel termed a biopsychosocial approach, even
with a hard-core genetic disease. We found significant numbers of depressed,
obese, diabetic patients with "arthritis" from fibromyalgia
showing up desperately hoping they had hemochromatosis so they finally
could be understood and treated! Why had they not been recognized and
treated? Why were they fat? Why depressed? Why were they in a state
of chronic muscle tension? Why had we failed them?
Vision Testing for Dementia
Peter N Rosen, MD's interesting article about
using simple although unconventional forms of vision testing for the
very early diagnosis of dementia offers new opportunities for secondary
prevention, particularly when it comes at the time pharmacotherapy is
beginning to show some promise in treating dementia. Yet to be discovered
are the emotional threats resulting from such early diagnosis and how
we will deal with them.
Role of Preventive Medicine
Eric Blau, MD, FACP, internist and now head of Preventive Medicine in
KP San Diego, closes the trail with his ideas
about the role Preventive Medicine should have in KP and how it might
be laid out organizationally. You may remember him from his fine photojournalistic
article, "In the Shadow of Obesity,"3 an unconventional
foray into Preventive Medicine. It turns out that the arts can have
a meaningful role in medical practice because they help circumvent the
resistance we all have to discussing personally threatening subjects.
The Importance of Asking
back, Preventive Medicine has been an unexpectedly interesting and even
sometimes exciting discipline. As an unintended but long-term participant
in the field, I must share several observations. First is the importance
of a biopsychosocial approach; few things are less acceptable than telling
someone to stop doing something when one doesn't understand why they
are doing it; at some level, all behaviors are functional. Without such
understanding, one risks mouthing banalities like the platitude for
resolving the use of street drugs: "Just say No." The
real question in Preventive Medicine and public health is Why
is this individual an addict? Why is that one obese? Why
did this patient pursue a lifestyle that led to suicide, coronary artery
disease, or COPD? In the ACE Study, one of the most important observations
was that many intractable public health problems are also
personal solutions to problems well hidden, once again, by time,
secrecy, shame, and social taboo.
familiar with the Adverse Childhood Experiences (ACE) Study will have
an understanding of the need to screen routinely for adverse childhood
experiences in all patients; to have an awareness of the relevance
of adverse childhood experiences to intractable conditions and "problem
patients"; and to have a sense of appropriate approaches to treatment
that need to be devised for each case. Analysis of a 125,000-patient
cohort where such comprehensive biopsychosocial screening routinely
was used showed a 35% reduction in doctor office visits (DOVs) during
the following year (HNC Corporation. Health Appraisal Study
Final Report, unpublished data, 1996). By contrast, in 1977, a purely
biomedical approach in the same Department of Preventive Medicine produced
an 11% net reduction in DOVs.a The implications for medical
practice of this comprehensive, preventive, biopsychosocial approach
are profound; it provides a new and improved platform of information
upon which to base primary care medicine.
Kaiser Permanente Institutes
of Preventive Medicine
forward, Preventive Medicine offers the real possibility of being the
future of Kaiser Permanente. Imagine a nationwide system of KP Institutes
of Preventive Medicine providing a uniform, nationwide mechanism of
member entry into the KP Program--routinely providing, at member entry,
an in-depth base of standardized medical information for patient care,
medical research, and administrative planning and open to the public
to provide a powerful marketing tool.
A Doctor Whom a Patient
these are only techniques. Sir James Spence, an English pediatrician,
understood this years ago, when he wrote, "The real work of a doctor
is not an affair of health centres, or public clinics, or operating
theatres, or laboratories, or hospital beds. These techniques have their
place in medicine. The essential unit of medical practice is the occasion
when, in the intimacy of the consulting room or sick room, a person
who is ill, or believes himself to be ill, seeks the advice of a doctor
whom he trusts. This is the consultation, and all else in the practice
of medicine derives from it."4
view of Preventive Medicine as population-based, comprehensive biopsychosocial
screening of all individuals, coupled with matching risk abatement programs,
has been tested and developed in KP; this screening has been done affordably
and with measured benefit. If this vision of Preventive Medicine were
routinely used as the entry point for all ongoing medical care, the
resulting new platform of starting information would enable Primary
Care practitioners to fulfill Sir James Spence's proposition.
communication, in 1977, with Joel Kovner, DrPH, about an analysis
by the Department of Medical Economics of 700 patients going through
Health Appraisal, measuring the effect of that experience on Doctor
Office Visits in the year subsequent compared with the year before.
RJ. Growing Up Fast, by Joanne Lipper. Perm J 2003 Fall;7(4):77-8.
VJ. The relation between adverse childhood experiences and adult health:
turning gold into lead. Perm J 2002 Winter;6(1):44-7.
EM. In the shadow of obesity. Perm J 2000 Summer;4(3):47-55.
James. The need for understanding the individual as a part of the
training and functions of doctors and nurses. [Speech delivered at
a conference on mental health held in March 1949]. In: The purpose
and practice of medicine: selections from the writings of Sir James
Spence. London: Oxford University Press; 1960, p 273-4.
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