preventive medicine

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The branch of medicine that is concerned with the prevention of disease and methods for increasing the power of the patient and community to resist disease and prolong life.

Preventive medicine is a specialty of medicine practiced by physicians devoted to health promotion and disease prevention. Physicians with expertise in preventive medicine are typically interested in health problems that have a significant impact on specific populations, such as those with multiple risk factors for cardiovascular disease, a highly prevalent condition. Conversely, a disease may become the focus of preventive medicine despite its low prevalence because it causes significant illness, disability, and death (e.g., a disease with a high case-fatality rate such as infection with the Ebola virus). Other health problems important to preventive medicine are those that disproportionately affect one narrow segment of a population, such as unintended pregnancies among urban adolescents.

Physicians who practice preventive medicine may work with individual patients in the delivery of clinical preventive services, or they may serve a defined population. In either case, the goal is to reduce the risk factors of the patient or the population that contribute to premature morbidity and mortality. Traditionally, in the United States, the medical and public health communities have assessed the diseases that cause the most mortality and have intervened to reduce their impact. Heart disease and cancers of all types remain leading causes of premature mortality. Recently, the emphasis has shifted from concentrating on diseases that are highly prevalent to a focus on the actual behaviors that cause these conditions. By approaching threats to good health in this way, behaviors such as smoking, unsafe sexual practices, dietary habits, and lack of exercise emerge as vitally important in determining disease or its absence. Preventive-medicine physicians embrace this approach to shape intervention strategies to target behaviors that cause disease.

The American Board of Medical Specialties recognizes preventive medicine as one of the twenty-four distinct medical specialties. Since 1950, the American Board of Preventive Medicine (ABPM) has certified over 7,800 physicians as specialists in preventive medicine. Of the living diplomates (physicians board certified by ABPM) in 1999, 2,752 were in public health/general preventive medicine, 2,442 were in occupational medicine, and 897 were in aerospace medicine. The American Medical Association database on physicians who designate themselves as preventive-medicine specialists reveals a decline in this specialty practice from 2.3 percent of all United States physicians in 1970 to 0.9 percent in 1997; the greatest decline has been in the area of public health and general preventive medicine. Although the needs of the public health work force have not been fully elucidated, and many factors determine physician specialty choice, the following contribute to declining participation in the field: the lack of awareness of the field of preventive medicine, the absence of requirements for certification in many public health and general preventive medicine positions, and inadequate funding during residency training. Despite their small numbers, experts in the field, as well as the collective action of professional societies that bring preventive-medicine specialists together, have been in the forefront among all medical specialties in clearly defining the knowledge and skills needed to master and the professional competencies to be used as the basis for residency training in preventive medicine.

Physicians who become diplomats of the American Board of Preventive Medicine are uniquely trained in both clinical and population-based medicine. Residency training requires a minimum of one year of training in an accredited clinical program, an academic year that almost always leads to a master's degree in public health (M.P.H.), and a practicum year that provides trainees with experience in the application of the knowledge and skills of preventive medicine in diverse settings.

The didactic component of preventive-medicine training provides the core knowledge and skills that encompass the major public health disciplines. The areas of public health in which a preventive-medicine physician must become competent are epidemiology; biostatistics; environmental and occupational health; planning, administration, and evaluation of health services; the behavioral aspects of health and disease; and the practice of preventive medicine in clinical settings. The first five areas represent the core of public health and are required of M.P.H. programs for certification by the Council on Education in Public Health. Epidemiolgy and biostatistics are the fields that define, describe, and quantify diseases and disease patterns; environmental and occupational health and the behavioral sciences cover major determinants of whether diseases flourish, diminish, or exist at all in populations; and planning, administration, and evaluation of health services encompass the competencies needed by programs and health care systems to address specific diseases and/or population-based health programs and evaluate the effectiveness of interventions.

Preventive medicine physicians must be skilled in the clinical practice of health promotion and disease prevention. They must also understand evidence-based medicine in order to know what screening tests and interventions are appropriate for their patients. Evidence-based medicine is a method for determining the content of clinical care that involves evaluating the scientific evidence supporting a particular diagnostic test or therapy and deciding whether the evidence is sufficient to establish the efficacy and effectiveness of an intervention. Preventive medicine physicians must have a good knowledge of this approach to medicine and must be able to incorporate the findings in their practices in order to evaluate their patients and provide appropriate counseling, testing, and preventive therapy.

Preventive medicine physicians have numerous employment opportunities. Many primarily practice population-based medicine and work for local, state, federal, or international health departments; the military; or large employers such as managed care organizations. Consulting opportunities exist for specialists in epidemiology; disease management systems; and program development, implementation, and evaluation. Preventive-medicine physicians also teach and conduct research in schools of public health and medicine and deliver direct patient care.

(SEE ALSO: Clinical Preventive Services; Evidence-Based Medicine; Health Promotion and Education; Healthy People 2010; Prevention; Preventive Health Behavior; Primary Prevention; Secondary Prevention; Tertiary Prevention)

Bibliography

Lane, D. S. (2000). "A Threat to the Public Health Workforce: Evidence from Trends in Preventive Medicine Certification and Training." American Journal of Preventive Medicine 18(1):87–96.

McGinnis, J. M., and Foege, W. H. (1993). "Actual Causes of Death in the United States." Journal of the American Medical Association 270(18):2207–12.

Woolf, S. H.; Jonas, S.; and Lawrence, R. S., eds. (1996). Health Promotion and Disease Prevention in Clinical Practice. Baltimore, MD: William and Wilkins.

— MIRIAM ALEXANDER; ROBERT S. LAWRENCE

A branch of medicine that promotes activities to prevent the occurrence of disease.

(DOD) The anticipation, communication, prediction, identification, prevention, education, risk assessment, and control of communicable diseases, illnesses and exposure to endemic, occupational, and environmental threats. These threats include nonbattle injuries, combat stress responses, weapons of mass destruction, and other threats to the health and readiness of military personnel. Communicable diseases include anthropod-, vector-, food-, waste-, and waterborne diseases. Preventative medicine measures include field sanitation, medical surveillance, pest and vector control, disease risk assessment, environmental and occupational health surveillance, waste (human, hazardous, and medical) disposal, food safety inspection, and potable water surveillance. Also called PVNTMED.

Preventive medicine or preventive care refers to measures taken to prevent diseases,^[1] (or injuries) rather than curing them. It can be contrasted not only with curative medicine, but also with public health methods (which work at the level of population health rather than individual health).

Contents 1 Levels 2 Universal, selective, and indicated 3 Professionals 4 Prophylaxis 4.1 Examples 5 Leading cause of preventable death 6 See also 7 References 8 External links

Levels

This takes place at primary, secondary and tertiary prevention levels.

1. Primary prevention avoids the development of a disease.^[2] Most population-based health promotion activities are primary preventive measures.
2. Secondary prevention activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease^[3] and emergence of symptoms.
3. Tertiary prevention reduces the negative impact of an already established disease by restoring function and reducing disease-related complications.^[4]

Simple examples of preventive medicine include hand washing and immunizations. Preventive care may include examinations and screening tests tailored to an individual's age, health, and family history. For example, a person with a family history of certain cancers or other diseases would begin screening at an earlier age and/or more frequently than those with no family history. On the other side of preventive medicine, some non-profit organizations, such as the Northern California Cancer Center, apply epidemiological research towards finding ways to prevent diseases.

Universal, selective, and indicated

Gordon (1987) in the area of disease prevention,^[5] and later Kumpfer and Baxley in the area of substance use^[6] proposed a three-tiered preventive intervention classification system: universal, selective, and indicated prevention. Amongst others, this typology has gained favour and is used by the U.S. Institute of Medicine, the NIDA and the European Monitoring Centre for Drugs and Drug Addiction.

1. Universal prevention addresses the entire population (national, local community, school, district) and aim to prevent or delay the abuse of alcohol, tobacco, and other drugs. All individuals, without screening, are provided with information and skills necessary to prevent the problem.
2. Selective prevention focuses on groups whose risk of developing problems of alcohol abuse or dependence is above average. The subgroups may be distinguished by characteristics such as age, gender, family history, or economic status. For example, drug campaigns in recreational settings.
3. Indicated prevention involves a screening process, and aims to identify individuals who exhibit early signs of substance abuse and other problem behaviours. Identifiers may include falling grades among students, known problem consumption or conduct disorders, alienation from parents, school, and positive peer groups etc.

Outside the scope of this three-tier model is environmental prevention. Environmental prevention approaches are typically managed at the regulatory or community level, and focus on interventions to deter drug consumption. Prohibition and bans (e.g. smoking workplace bans, alcohol advertising bans) may be viewed as the ultimate environmental restriction. However, in practice environmental preventions programmes embrace various initiatives at the macro and micro level, from government monopolies for alcohol sales, through roadside sobriety or drug tests, worker/pupil/student drug testing, increased policing in sensitive settings (near schools, at rock festivals), and legislative guidelines aimed at precipitating punishments (warnings, penalties, fines).

Professionals

Professionals involved in the public health aspect of this practice may be involved in entomology, pest control, and public health inspections. Public health inspections can include recreational waters, pools, beaches, food preparation and serving, and industrial hygiene inspections and surveys.

In the United States, preventive medicine is a medical specialty, one of the 24 recognized by the American Board of Medical Specialties (ABMS). It encompasses three areas of specialization:

• General preventive medicine and public health
• Aerospace medicine
• Occupational medicine

In order to become board-certified in one of the preventive medicine areas of specialization, a licensed U.S. physician (M.D. or D.O.) must successfully complete a preventive medicine medical residency program following a one-year internship. Following that, the physician must complete a year of practice in that special area and pass the preventive medicine board examination. The residency program is at least two years in length and includes completion of a master's degree in public health (MPH) or equivalent. The board exam takes an entire day: the morning session concentrates on general preventive medicine questions, while the afternoon session concentrates on the one of the three areas of specialization that the applicant has studied.

In addition, there are two subspecialty areas of certification:

• Medical toxicology (MT)
• Undersea and hyperbaric medicine (UHB), formerly "undersea medicine"

These certifications require sitting for an examination following successful completion of an MT or UHB fellowship and prior board certification in one of the 24 ABMS-recognized specialties.

Prophylaxis

Prophylaxis (Greek "προφυλάσσω" to guard or prevent beforehand) is any medical or public health procedure whose purpose is to prevent, rather than treat or cure a disease. In general terms, prophylactic measures are divided between primary prophylaxis (to prevent the development of a disease) and secondary prophylaxis (whereby the disease has already developed and the patient is protected against worsening of this process).

Examples

Some specific examples of prophylaxis include:

• Influenza vaccines are prophylactic.^[7]
• Antibiotics are sometimes used prophylactically: For example, during the 2001 anthrax attacks scare in the United States, patients believed to be exposed were given ciprofloxacin. In similar manner, the use of antibiotic ointments on burns and other wounds is prophylactic. Antibiotics are also given prophylactically just before some medical procedures such as pacemaker insertion.^[8]
• Tricyclic antidepressants (TCAs) may, with caution, be an example of a chronic migraine preventative (see Amitriptyline and migraines' prevention by medicine).
• Antimalarials such as chloroquine are used both in treatment and as prophylaxis by visitors to countries where malaria is endemic to prevent the development of the parasitic Plasmodium, which cause malaria.
• Condoms are sometimes referred to as "prophylactics" because of their use to prevent the transmission of sexually transmitted infections.
• Low-molecular-weight heparin is used as a prophylaxis in hospital patients, as they are at risk for several forms of thrombosis due to their immobilisation.
• Professional cleaning of the teeth is dental prophylaxis.
• Risk Reducing or Prophylactic Mastectomies may be carried out for carriers of the BRCA mutation gene to minimise the risk of developing Breast Cancer
• Daily and moderate physical exercise in various forms can be called prophylactic because it can maintain or improve one's health. Cycling for transport appears to very significantly improve health by reducing risk of heart diseases, various cancers, muscular- and skeletal diseases, and overall mortality^[9].
• Prophylaxis may be administered as vaccine. Prophylactic vaccines include: PEP, nPEP, PREP, or nPREP. PEP stands for post-exposure prophylaxis used in an occupational setting. nPEP is non-occupational post-exposure prophylaxis. nPEP may be used in a recreational setting; for example, during intercourse, if the condom breaks and one partner is HIV-positive, nPEP will help to decrease the probability of spread of infection of HIV. PREP is often used in occupational settings, e.g., in hospital staff to prevent the spread of HIV or Hepatitis C from patient to staff. nPREP is a measure taken before exposure but in a non-occupational setting (non-occupational Pre-exposure prophylaxis); for example, injection drug users may seek nPREP vaccinations.

Leading cause of preventable death

See also: List of preventable causes of death

The examples and perspective in this section may not represent a worldwide view of the subject. Please improve this article and discuss the issue on the talk page. (June 2009)

Leading causes of preventable deaths in the United States in the year 2000.^[10]

Cause	Number of deaths resulting
Tobacco Smoking	435,000 deaths or 18.1% of the total deaths
Overweight and Obesity	365,000 deaths or 15.2% of the total deaths.
Alcohol consumption	85,000 deaths or 3.5% of the total deaths.
Infectious diseases	75,000 deaths or 3.1% of the total deaths.
Toxicants	55,000 deaths or 2.3% of the total deaths.
Traffic collisions	43,000 deaths or 1.8% of the total deaths.
Incidents involving firearms	29,000 deaths or 1.2% of the total deaths.
Sexually transmitted diseases	20,000 deaths or 0.8% of the total deaths.
Drug abuse	17,000 deaths or 0.7% of the total deaths.

See also

• Pre-exposure prophylaxis
• Post-exposure prophylaxis
• Prophylaxis (chess)
• Prophylactic rule

References

1. ^ MeSH Preventive+Medicine
2. ^ MeSH Primary+Prevention
3. ^ MeSH Secondary+Prevention
4. ^ MeSH Tertiary+Prevention
5. ^ Gordon, R. (1987), ‘An operational classification of disease prevention’, in Steinberg, J. A. and Silverman, M. M. (eds.), Preventing Mental Disorders, Rockville, MD: U.S. Department of Health and Human Services, 1987.
6. ^ Kumpfer, K. L., and Baxley, G. B. (1997), 'Drug abuse prevention: What works?', National Institute on Drug Abuse, Rockville.
7. ^ How should influenza prophylaxis be implemented?
8. ^ de Oliveira JC, Martinelli M, D'Orio Nishioka SA, et al. (2009). "Efficacy of antibiotic prophylaxis prior to the implantation of pacemakers and cardioverter-defibrillators: Results of a large, prospective, randomized, double-blinded, placebo-controlled trial". Circ Arrhythmia Electrophysiol 2: 29–34. doi:10.1161/CIRCEP.108.795906. 
9. ^ Lars Bo Andersen et al. (June 2000). "All-cause mortality associated with physical activity during leisure time, work, sports, and cycling to work.". Arch Intern Med. 160 (11): 1621–8. doi:10.1001/archinte.160.11.1621. PMID 10847255. 
10. ^ Mokdad AH, Marks JS, Stroup DF, Gerberding JL (March 2004). "Actual causes of death in the United States, 2000". JAMA 291 (10): 1238–45. doi:10.1001/jama.291.10.1238. PMID 15010446. http://www.csdp.org/research/1238.pdf. 

External links

• Association of Preventive Medicine Residents
• US Preventive Medicine
• The Prevention Plan
• American College of Preventive Medicine
• American Board of Medical Specialties
• American Board of Preventive Medicine
• American College of Veterinary Preventive Medicine

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