Clinical Preventive Medicine

by

Mark B. Johnson

• LAST REVIEWED: 30 September 2013
• LAST MODIFIED: 30 September 2013
• DOI: 10.1093/obo/9780199756797-0117

Introduction

The clinical practice of preventive medicine has long been the dream of many who have believed that its promise is too great to ignore. But the actual history of clinical preventive medicine has been much more complex, and often much less rewarding, than these dreamers anticipated. Humanitarians have believed that its promise was in preventing, delaying, decreasing, or eliminating the pain and suffering that accompanies most morbid conditions, while government officials, insurance executives, and economists have more often focused on the potential cost savings it appears to promise. In the journey toward that promise, clinical preventive medicine has gone through several evolutionary changes as it rather unsuccessfully has attempted to define and promote itself in a more attractive and convincing manner to the practicing clinician. Three major complications have hampered its progress and acceptance in the medical community. First, the attractive insinuation that clinical preventive medicine would lead to cost savings has put it in the unenviable position of being measured and judged solely by its economic benefits, a disadvantage not shared with most other clinical modalities. When those savings have not been forthcoming, or when they have not been as great as expected, the medical community and health-care payers have been quick to discount its value. Second, unlike many bodies of medical knowledge that fall cleanly under the purview of a specific medical specialty, the practice of clinical preventive medicine intersects with the practice of almost all of the recognized medical specialties as well as with many other professional fields, both clinical and nonclinical, outside medicine. The knowledge, skills, and competencies required to practice clinical preventive medicine are oftentimes intensive, both in acquisition and provision (e.g., counseling and patient education), and they are either poorly remunerated or may be better provided by ancillary staff, such as nurses, dietitians, exercise physiologists, or behavioral scientists. Defining the unique and appropriate role of the physician in clinical prevention continues to be a point of deep debate and discussion in the medical community. A transformational change in this area may be occurring, however, as a growing number of physicians who claim to be practicing what is being called “lifestyle medicine” take on and greatly expand the scope of what has traditionally been called the practice of clinical preventive medicine. And finally, those who practice alternative and complementary medicine have been very successful in capturing and proclaiming the promise of clinical prevention to the media and lay public while often neglecting or bypassing the rigor required to ensure that their practices are based on scientific evidence.

Introductory Works

The sweep of clinical preventive medicine is well represented by the works given here. Stokes, et al. 1982 defines the terms that are used in the field and describes the general concepts on which the field has been built, defining clinical preventive medicine as “those personal health services, provided within the context of clinical medicine,” by which health is maintained and disease risk and untimely death are reduced. The extent of preventable disease and death in the United States is described in McGinnis and Foege 1993 in a novel and thought-provoking manner, and the seminal works Frame and Carlson 1975 and Breslow and Somers 1977 establish guidelines and schedules to formalize the periodic health examination, in a move away from the traditional annual physical examination. Canadian Task Force on the Periodic Health Examination 1979 took this field to new levels of scientific rigor by setting strict standards for the acceptability of various levels of evidence and utilizing a meticulous methodology in reviewing an increasing list of suggested and recommended screening tests. All subsequent activities of the US Preventive Services Task Force, the Canadian Task Force on Preventive Health Care, and the numerous specialty association guideline production committees truly stand on the shoulders of the original work of the Canadian Task Force on the Periodic Health Examination.

• Breslow, Lester, and Anne R. Somers. 1977. The lifetime health-monitoring program: A practical approach to preventive medicine. New England Journal of Medicine 296.11: 601–608.

  DOI: 10.1056/NEJM197703172961104

  This article further refined recommendations for ethical periodic screening examinations, and added more economical insights into the evidence on which those recommendations were based.

• Canadian Task Force on the Periodic Health Examination. 1979. The periodic health examination. Canadian Medical Association Journal 121.9: 1193–1254.

  This article exponentially expanded the scope of services reviewed and recommended, and it established the “most rigorous, detailed and comprehensive evaluation of the periodic health examination to date.” It also refined the definitions used in the field, and it set detailed criteria for the assessment of potentially preventable conditions that are the basis of all further work in this area.

• Canadian Task Force on Preventive Health Care.

  The site of the reconstituted Canadian Task Force, with additional interventions reviewed and updates refining the work of the first group.

• Frame, Paul S., and Stephen J. Carlson. 1975. A critical review of periodic health screening using specific screening criteria. Part 1: Selected diseases of respiratory, cardiovascular, and central nervous systems. Journal of Family Practice 2.1: 29–36.

  First of four articles that reviewed the literature on the periodic health screening up to this point, and that redefined it on a scientifically sound basis. Defined the criteria needed to justify screening programs, and formulated recommendations based on those criteria. Series continued in the Journal of Family Practice 2.2: 123–129 (Part 2: Selected Endocrine, Metabolic, and Gastrointestinal Diseases); 2.3: 189–194 (Part 3: Selected Diseases of the Genitourinary System); and 2.4: 283–289 (Part 4: Selected Miscellaneous Diseases).

• McGinnis, J. Michael, and William H. Foege. 1993. Actual causes of death in the United States. Journal of the American Medical Association 270.18: 2207–2212.

  DOI: 10.1001/jama.1993.03510180077038

  Creatively moved behind the leading cause of death indicators to focus on the true or “actual” causes of those deaths, thus opening a new vista on how such deaths might be prevented.

• Stokes, Joseph, III, Jay Noren, and Sidney Shindell. 1982. Definition of terms and concepts applicable to clinical preventive medicine. Journal of Community Health 8.1: 33–41.

  DOI: 10.1007/BF01324395

  This article by a committee of the American Teachers of Preventive Medicine Foundation helped set the stage for clinical preventive medicine by clarifying the definitions and terms that are used in the field.

• US Preventive Services Task Force.

  This site continues the work of the original task force by updating recommendations based on new information and by increasing the number of interventions reviewed.

• US Preventive Services Task Force. 1989. Guide to clinical preventive services: An assessment of the effectiveness of 169 interventions. Baltimore: Williams & Wilkins.

  Working on the foundation set by the Canadian Task Force on the Periodic Health Examination, this guide expanded the number of interventions reviewed and formalized the evidence-based criteria needed for such a review.