Quaternary Prevention

Gene WW Tsoi 蔡惠宏

HK Pract 2014;36:49-50

When I started my private practice in Hong Kong about 25 years ago, I bought some books from London to “decorate” my book-shelf in the consultation room. Books on topics for General Practice were few in the book-stores. One was “Preventive Medicine in General Practice”, first published in 1983. I bought that book because I had not been taught formally about what is preventive medicine. The book had different chapters dealing with principles and practice of preventive medicine. It also gave the definitions of primary, secondary, tertiary prevention, and anticipatory care. There was no such thing as Quaternary Prevention at that time.

Then I came across this item, Quaternary Prevention (QP) about 2 years ago when I represented our College at the WONCA International Classification Committee (WICC). The Committee was a group of dedicated academic general practitioners (GPs) responsible for the creation of the ICPC code which is now widely used by GPs throughout the world. I am sure our young college Fellows enrolled in our Hospital Authority vocational training programme are familiar with this coding system.

With the classification and data collection activities arising from the ICPC coding, the Committee noticed the tremendous development in prevention advices and activities not just by GPs, but also by other specialists during the past two decades. As a result of this, another product emerged from WICC which is the website “Primary Health Care Classification Consortium” (PH3C) for Quaternary Prevention and has become a core objective of WICC. PH3C has given a definition to Quaternary Prevention: “Action taken to identify a patient or a population at risk of over-medicalisation, to protect them from invasive medical intervention and provide them with care procedures which are ethically acceptable.” I would like to quote two most common and well accepted practices as examples which I believe, would not draw much strong disagreement among the medical profession at large:

l anti-smoking campaign for prevention of lung cancers; and

lŸŸŸŸ Paps smear screening for early detection of cervical cancer.

But since then, there have been lots of controversies in the many prevention and screening recommendations within the medical profession over the years.

With the advances in modern medical technology, in particular during the past 20 years, biochemical testing, body imaging, genome studies, revolutionary surgical techniques have brought dramatic changes in investigation, treatment and patient management. The concept of illness and health has also changed. Prevention strategies and recommendations for early detection of diseases, especially cancers, have been disseminated via the new era of communication channels, most noticeably in the internet.

The emergence of Evidence-based Medicine (EBM) has been responsible for the rapid changes in clinical practice, in particular prevention concepts. Medical practitioners who want to deliver good quality medicine and care to meet patients’ expectations need to practise in accordance with the latest evidence. However, one must be very careful because recently there is a paper published in the April 2014 issue Journal of Evaluation in Clinical Practice about EBM. The title is “The lack of evidence for the benefits of EBM”. Reader interested in the article can go to the link http://onlinelibrary.wiley.com to access the full text.

For example, in my early days of general practice, I used to advise health check-up such as an annual chest X-ray and simple blood profiles. The annual chest X-ray was advised because pulmonary tuberculosis was very prevalent and lung cancer was the leading cause of death from malignancy. However, studies about early detection of lung cancer did not show evidence in support of such practice; therefore I stopped advocating annual chest X-ray for this purpose. 

Dr Marc Jamoulle is a veteran member of the WICC and the forerunner in Quaternary Prevention. He presented a poster on this topic in Hong Kong back in 1995 World WONCA. The term is later formally adopted by WONCA. I am very pleased that he has been invited to contribute an article to enlighten our fellow family physicians in Hong Kong.

The roles of family physicians are many: as a healer, a coordinator of healthcare for patients, a health advocate as well as an educator to the public. Naturally, Quaternary Prevention has become one of the explicit roles of a family physician. I think most family physicians have practised QP to some extent. But, are we organised within our own discipline of family medicine? How well are we equipped with the necessary knowledge and skills; and how much do we differ among ourselves in our attitude towards health, diseases and illnesses, risk tolerance, life and death? How should our next generation of family physicians be trained to achieve what QP is currently defined.

Our team of writers from the Public Education Committee has regularly contributed articles in the newspapers to educate the public on health and disease concepts and management from the perspective of a family physician. One of the writers, a very able and experienced family physician, has recently written an article about the pros and cons of the use of annual mammography for population screening of breast cancer. I was not surprised to find in another newspaper, shortly afterwards, a prominent breast surgeon in private practice, wrote another article to rebuke our writer with certain malicious comments which were close to a personal attack. This truly reflects the difficulties and stress that a family physician may have to face against other specialists and his patients as well.

Today, the development of QP is most robust in South America and continental Europe. I have been linked to the core group in the WICC on the internet in the past two years. The information shared everyday was enormous, stimulating and at times provoking. The messages are now spreading around major newspapers and media, and not just restricted to academic journals only. I have tried to ask around my contemporaries in Hong Kong but not many showed much interest or awareness of this new term in prevention. I hope with this issue of our journal Dr Jamoulle’s article on this topic, QP, it can stimulate an interest among members and more formal discussions will be organised in the future by our College. As an academic College, we have the duty to advocate formal teaching in both our medical schools, set the standard of postgraduate training for QP relevant to the standard of local practice. We should encourage academic and inter-professional exchange of views and opinions in various prevention issues, public education on health informatics, and to give advice to healthcare policy-makers in the planning and delivery of appropriate screening programmes and prevention promotion.

Quaternary Prevention is the way forward.