Clinical prevention—docs lead the way

Doctors are often portrayed as tech­nophiles who make lavish use of resources to fight disease once it has already occurred. In the minds of many people, including the popular press and government health agencies, doctors are only experts at treating existing illnesses.

Indeed, across Canada, physician compensation is aligned with the above preconceived notion. In BC, aside from a new cardiovascular prevention fee item achieved through the work of GPSC, there is no MSP fee targeted to clinical prevention. Yet prevention is a large part of medical practice. Entire public health programs and departments are headed by physicians trained in community medicine. 

At a political level, the CMA and its divisions (particularly the BCMA) have been active in promoting preventive measures ranging from clean air to bicycle safety. Most importantly, doctors screen, treat, advise, and empower patients every day in ways that keep them healthy and free of illness.

Disease prevention takes many forms, ranging from measures such as speed limits to prevent the emergence of illness (primordial prevention) to interventions such as medication monitoring to prevent further harm once disease treatment is underway (quaternary prevention). Many prevention services—immunizations, rectal exams, smoking cessation advice, etc.—are maneuvers that are delivered in an interaction between a pro­vider and a patient. 

It is these clinical prevention services that are very much part of everyday practice, and physicians’ practices are ideally suited to provide the expertise, credibility, and longitudinal care that allows for a full suite of services—a lifetime prevention schedule—to be offered to patients. 

Government clearly recognizes the value of clinical preventive services. Across the province is a somewhat porous patchwork of funding, service delivery, and reminder systems that varies from region to region. In Vancouver, for example, most childhood immunizations are delivered by phy­sicians, whereas outside the large population centres, almost all are delivered by public health. 

Notwithstanding the fact that some prevention services (e.g., mammography) require special equipment not found in physicians’ practices, the vast majority of services can be delivered through a physician’s practice (either by doctors or physician extenders). This presents several advantages to the delivery of preventive care:

One-stop shopping. Because so many patient encounters involve multiple issues, it makes great sense to have clinical prevention delivered in the same place (and sometimes in the same visit). Patients are not separated from their primary care providers by having to navigate a maze of different providers, and the records and re­minders can be kept and coordinated by the physician’s practice.

Cost-effectiveness. Creating new levels of providers and administration to deliver a single clinical intervention is not optimal. Indeed, what we know about the effectiveness of clinical prevention is almost entirely derived from studies looking at physician providers. 

Doctors have an excellent track record of being able to efficiently deliver medical care, space, and staffing. Even with public health immunization clinics—the poster-child of nonphysician preventive care—it is difficult to demonstrate a cost saving over provision by doctors—and the analysis doesn’t begin to account for all the other unmet needs that will take the patient to their primary care providers anyhow.

Information technology. Electronic medical records (EMRs) have the capacity to incorporate reminders for patient and doctors of routine pre­ventive interventions. Furthermore, EMRs have the capacity to receive information from other providers so that information on vaccines, cancer screening, smoking reduction, and so on can be coordinated by the family physician. 

This can happen when the intervention is done by someone other than the patient’s primary care pro­vider. It is all too possible for people to fall between the cracks in the current system, and a technological system that allows for a coordinated health maintenance record will be a big step in closing that gap.

Patient preference. Patients prefer to have clinical prevention done by their doctors. Public polling from early 2010 (BCMA Omni Poll, January 2010) shows that when offered a choice from among a number of care providers, the large majority preferred clinical prevention to be delivered by doctors (59%) with the next largest group lagging at 11%. The numbers were more striking when it came to who should coordinate the information—FPs at 66% followed by nurses at 6%.

Doctors, the public, and government know the value of prevention. As more focus is put on this area, it is important to ensure that investments here are made in a way that doesn’t reinvent the wheel. We need to let our patients and government know that physicians and their practices offer the ideal delivery system for such services. 

An investment in clinical prevention coordinated through family practices allows those with the most training and credibility to efficiently deliver a lifetime prevention schedule to ensure good health.
—Lloyd Oppel, MD, Chair, Council on Health Promotion