Disease prevention through medical action and change of lifestyle has become one of the cornerstones of medicine in our days, and rightly so: advances such as childhood immunization and the generalization of breast-feeding, to name just two areas, were huge quality leaps in the health of contemporary societies. Actually, the success of preventive measures was such that it gave rise to unrealistic expectations about interventions classified as prevention; in addition, the notion that "better safe than sorry" is so ingrained in our culture that is now almost impossible to challenge any preventive measure without being immediately attacked by its supporters, often impermeable to facts that demonstrate that some preventive activities can not only be useless but manifestly harmful to patients.
This type of situation become particularly relevant when large groups of asymptomatic populations began to be screened. As they discussed the screenings, David Sackett and Walter Holland observed that "the advocates of screening, usually for faultless reasons, conclude that pre-existing evidence, added to common sense, faced with the continued price of disability and early death, requires mass screening programmes [...] In order “to keep to the faith," the advocates of screening may find themselves forced to accept or reject the evidence, not so much based on its scientific merit, but because this evidence supports or rejects the proposition that screenings are good. "(Sackets and Holland, 1975). The same Sackett, years later, debated what he described as "the arrogance of preventive medicine" (Sackett, 2002) with regard to the results of the study Women's Health Initiative (Writing Group for the Women's Health Initiative Investigators, 2002), which demonstrated the harmful effects of hormone replacement therapy, an intervention hitherto heavily encouraged among post-menopausal women. The fact that the concept of prevention extended so as to include risk factors as if they were diseases has also been subject to criticism (Starfield et al, 2008). The progressive decrease of the threshold above which one defines the presence of disease - hypertension, dyslipidemia and diabetes are the most immediate examples - means that many millions of asymptomatic persons until now considered to be healthy are classified as sick or potentially sick (Westin and Health, 2005).
The concept of quaternary prevention arises from the awareness that excessive medical intervention can do more harm than good. Marc Jamoulle and Michael Roland, taking as their starting point the Hippocratic precept primum non nocere, advanced the concept of quaternary prevention, defining it as an "initiative to identify patients at risk of overmedication, to protect them from further medical invasions and to propose to patients ethically acceptable interventions "(Jamoulle and Roland, 2005). Conceived after the definitions of primary, secondary and tertiary prevention, quaternary prevention focuses on individuals who feel ill but have no pathological record that justifies their complaints or has a direct relationship with them (Kuehlein et al, 2010) (Figure 1). This concept is now well established in general and family medicine around the world (Bentzen, 2003).
Quaternary prevention is practiced on a daily basis with patients who resort to their doctors. The principles that govern it are, briefly, the following (Melo, 2007):
• Adopt a biopsychosocial perspective, looking at the patient globally and practice a patient-centred approach.
• Accept that some complaints are unexplainable.
• Avoid pseudo-diagnoses and labels.
• Work on strengthening the doctor-patient relationship.
• Involve the patient in decisions.
• Keep abreast of technical and scientific matters resorting to independent and unbiased information, and maintain a constant critical stance about the information received.
• Use tools that enable the best medical practices. The best way to achieve this is to use protocols (diagnoses and therapeutic) that have been peer-developed, adapted locally and based on the best available evidence.
Nowadays, prevention is based on the identification and conversion of risk factors to prediction rules, turning the latter into decision rules, thus assuming relative risk as if it were absolute risk (Gérvas et al, 2008). The practice of quaternary prevention allows doctors to take maximum advantage of available interventions with patients who seek their help, protecting them from excessive interventions and their consequences.
Armando Brito de Sá
Auxiliary Guest Professor
Institute of Preventive Medicine
Faculty of Medicine of the University of Lisbon
abritosa@gmail.com
____________________________
Bibliographical references
Bentzen N (editor). [2003). WONCA Dictionary of General/Family Practice. Cope- nhagen, Maanedskift Lager.
Gérvas J, Starfield B, Heath I. (2008). Is clinical prevention better than cure? Lancet, 372, 1997-99.
Getz L, Sigurdson JA, Hetlevik I. (2003). Is opportunistic disease prevention in the consultation ethically justifiable? BMJ, 327, 498-500.
Heath I. (2005). Who needs health care—the well or the sick? BMJ, 330, 954-956.
Jamoulle M, Roland M. (2005, Junho 6-9). Quaternary prevention and the glossary of general practice/family medicine. Hong Kong WONCA Congress Proceedings. Hong Kong: WONCA - World Organization of Family Doctors.
Kuehlein T, Sghedoni D, Visentin G, Gérvas J. (2010). Quaternary prevention: a task of the general practitioner. Primary Care, 10 (18), 350-354.
Melo M. (2007). A prevenção quaternária contra os excessos da Medicina. Rev Port Clin Geral, 23, 289-293.
Sackett DL. (2002). The arrogance of preventive medicine. CMAJ, 167 (4), 363-364.
Sackett DL, Holland WW. (1975). Controversy in the detection of disease. Lancet, ii, 357-359.
Starfield B, Hyde J, Gérvas J, Heath I. (2008). The concept of prevention: a good idea gone astray? J Epidemiol Community Health, 62, 580-583.
Westin S, Heath I. (2005). Thresholds for normal blood pressure and serum cholesterol. BMJ, 330, 1461-1462.
Writing Group for the Women’s Health Initiative Investigators. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the Women’s Health Initiative randomized controlled trial. JAMA, 288 (3), 321-333.
This type of situation become particularly relevant when large groups of asymptomatic populations began to be screened. As they discussed the screenings, David Sackett and Walter Holland observed that "the advocates of screening, usually for faultless reasons, conclude that pre-existing evidence, added to common sense, faced with the continued price of disability and early death, requires mass screening programmes [...] In order “to keep to the faith," the advocates of screening may find themselves forced to accept or reject the evidence, not so much based on its scientific merit, but because this evidence supports or rejects the proposition that screenings are good. "(Sackets and Holland, 1975). The same Sackett, years later, debated what he described as "the arrogance of preventive medicine" (Sackett, 2002) with regard to the results of the study Women's Health Initiative (Writing Group for the Women's Health Initiative Investigators, 2002), which demonstrated the harmful effects of hormone replacement therapy, an intervention hitherto heavily encouraged among post-menopausal women. The fact that the concept of prevention extended so as to include risk factors as if they were diseases has also been subject to criticism (Starfield et al, 2008). The progressive decrease of the threshold above which one defines the presence of disease - hypertension, dyslipidemia and diabetes are the most immediate examples - means that many millions of asymptomatic persons until now considered to be healthy are classified as sick or potentially sick (Westin and Health, 2005).
The concept of quaternary prevention arises from the awareness that excessive medical intervention can do more harm than good. Marc Jamoulle and Michael Roland, taking as their starting point the Hippocratic precept primum non nocere, advanced the concept of quaternary prevention, defining it as an "initiative to identify patients at risk of overmedication, to protect them from further medical invasions and to propose to patients ethically acceptable interventions "(Jamoulle and Roland, 2005). Conceived after the definitions of primary, secondary and tertiary prevention, quaternary prevention focuses on individuals who feel ill but have no pathological record that justifies their complaints or has a direct relationship with them (Kuehlein et al, 2010) (Figure 1). This concept is now well established in general and family medicine around the world (Bentzen, 2003).
Image 1 – Model of table with two entries of the distinct forms of prevention (taken from Kuehlein et al, 2010 – translated by Gustavo Gusso, Portuguese version available at http://www.primary-care.ch/d/index.html)
Quaternary prevention is practiced on a daily basis with patients who resort to their doctors. The principles that govern it are, briefly, the following (Melo, 2007):
• Adopt a biopsychosocial perspective, looking at the patient globally and practice a patient-centred approach.
• Accept that some complaints are unexplainable.
• Avoid pseudo-diagnoses and labels.
• Work on strengthening the doctor-patient relationship.
• Involve the patient in decisions.
• Keep abreast of technical and scientific matters resorting to independent and unbiased information, and maintain a constant critical stance about the information received.
• Use tools that enable the best medical practices. The best way to achieve this is to use protocols (diagnoses and therapeutic) that have been peer-developed, adapted locally and based on the best available evidence.
Nowadays, prevention is based on the identification and conversion of risk factors to prediction rules, turning the latter into decision rules, thus assuming relative risk as if it were absolute risk (Gérvas et al, 2008). The practice of quaternary prevention allows doctors to take maximum advantage of available interventions with patients who seek their help, protecting them from excessive interventions and their consequences.
Armando Brito de Sá
Auxiliary Guest Professor
Institute of Preventive Medicine
Faculty of Medicine of the University of Lisbon
abritosa@gmail.com
____________________________
Bibliographical references
Bentzen N (editor). [2003). WONCA Dictionary of General/Family Practice. Cope- nhagen, Maanedskift Lager.
Gérvas J, Starfield B, Heath I. (2008). Is clinical prevention better than cure? Lancet, 372, 1997-99.
Getz L, Sigurdson JA, Hetlevik I. (2003). Is opportunistic disease prevention in the consultation ethically justifiable? BMJ, 327, 498-500.
Heath I. (2005). Who needs health care—the well or the sick? BMJ, 330, 954-956.
Jamoulle M, Roland M. (2005, Junho 6-9). Quaternary prevention and the glossary of general practice/family medicine. Hong Kong WONCA Congress Proceedings. Hong Kong: WONCA - World Organization of Family Doctors.
Kuehlein T, Sghedoni D, Visentin G, Gérvas J. (2010). Quaternary prevention: a task of the general practitioner. Primary Care, 10 (18), 350-354.
Melo M. (2007). A prevenção quaternária contra os excessos da Medicina. Rev Port Clin Geral, 23, 289-293.
Sackett DL. (2002). The arrogance of preventive medicine. CMAJ, 167 (4), 363-364.
Sackett DL, Holland WW. (1975). Controversy in the detection of disease. Lancet, ii, 357-359.
Starfield B, Hyde J, Gérvas J, Heath I. (2008). The concept of prevention: a good idea gone astray? J Epidemiol Community Health, 62, 580-583.
Westin S, Heath I. (2005). Thresholds for normal blood pressure and serum cholesterol. BMJ, 330, 1461-1462.
Writing Group for the Women’s Health Initiative Investigators. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the Women’s Health Initiative randomized controlled trial. JAMA, 288 (3), 321-333.
