The Trouble with Preventive Care

Submitted by Wajid Sayeed on April 21, 2012 - 12:26

I love CBC radio. I play it loud with the windows down while driving through quiet residential neighbourhoods. The content and production values surpass anything else on the radio in this country.  I had to turn off my radio to write this, because otherwise I'll be too distracted.  I continue to love it, despite the fact that my favourite show is being cancelled this summer, a decision for which I blame . . . well I won't get political here.

My second-favourite show, however, is Ideas, a show whose content is succinctly explained by its name. Last Thursday's show was a replay of a particularly intriguing interview with Dr. Vincent Felitti, a physician whose experiences in the intensive treatment of morbid obesity led him to the idea of "Adverse Childhood Experiences" (ACEs) - psychological traumas that lead to illness later in life, dramatically raising the risk of heart disease, cancer and other non-psychiatric illness.

The CDC's ACE modelAs Dr. Felitti relates, the CDC took up the idea and began to study it seriously, commissioning a study of over 17,000 people who were administered standardized questionnaires about their childhood experiences and their medical histories, and then followed prospectively. Some surprising results came out of it, as you'll hear in the program. There is now a large and growing body of literature on the long-term physical and mental effects of ACEs.

The effects are so dramatic, that I'm puzzled as to why I wasn't taught anything about this in medical school. The idea that people with bad childhoods wind up with mental illness and addictions was one I encountered fairly regularly, but the effect on non-psychiatric illness was, until I started residency in Winnipeg, well-obscured by all the other "evidence-based" stuff I was supposed to memorize.

"Name the trial that showed the benefit of spironolactone in CHF! . . .  Wrong answer! Bad medical student, no cookie for you!"
 
In residency I don't get much of a chance to ask my patients a lot of these questions.  90% of what I've done so far has been acute-care stuff, and it seems a bit awkward to broach the subject of whether or not daddy was an alcoholic while the COPD patient is struggling to breath.

That sort of epitomizes the problem with implementing preventive care strategies - physicians are almost the worst people to do it. We specialize in bandaid solutions because we don't arrive on the scene until long after the problems have started. The underlying causes are deeper, more chronic, and more complex than we have time or brain power for.

Preventive care strategies are the domain of public policy, and we don't want to be too political.

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Comments

Wonderful exploration of preventive care. I agree that the attraction of the "sexy" part of medicine (intubating the COPDer) is more than the attraction of the number-crunching epidemiologic piece commonly associated with prevention. However, the more I deal with insane situations (e.g., the alcoholic who presents 3 times a day), the more conviction I feel for prevention.

I haven't delved into Felitti's work, but I don't think his angle is that part of your pre-intubation questionaire should include childhood psychological trauma. Instead, I think the goal is to use that data to try to stop the early life causes well before they have turned into a serious medical condition.

tarek : )

I hope you have a nice day! Very good article, well written and very thought out. I am looking forward to reading more of your posts in the future.

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