What are the major differences between medicine and public health? What challenges do public health officials frequently ignore?
On Tuesday, I attended a seminar by Dr. Richard Schieber. Dr. Schieber was a practicing pediatrician, however for the last fifteen years he has worked as a medical epidemiologist for the CDC.
One of the major challenges facing the CDC is how to translate public health medical recommendations down to the clinical level. According to Schuster et al. (1998), little of public health care recommendations are preformed in the clinical setting. “Simple averages from a number of studies indicate that 50 percent of people received recommended preventive care; 70 percent, recommended acute care;… 60 percent, recommended chronic care.”
Why are these numbers so low? Well, public health officials have many recommendations. What if a physician is confronted with a patient who has diabetes and is also obese and a smoker. Will they be able to fulfill all the recommendations in the 15-20 minute time slot they have with their patient? Likely not.
A study by Yarnall et al. (2003) finds that “To fully satisfy the USPSTF [US Preventative Services Task Force] recommendations, 1773 hours of a physician’s annual time, or 7.4 hours per working day, is needed for the provision of preventive services. ”
Dr. Schrieber’s main point of the talk is that recommendations in and of themselves are not very useful. They must be “translated” so they are useful and feasible for both the medical provider and the patient. Further, public health programs should be measured by outcomes, not by processes.
Finally, some of the talk was spent on differences between public health and medicine. Some of these differences are listed below.
| Medicine | Public Health | |
| Scope | Individual | Populations |
| Boss | CEO or MD | Bureaucrat |
| Environment | Clinical | Desk Job |
| Salary | High | Not as high |
| Satisfiers | Positive patient outcome | Vague |
| Language | Very Technical (Greek) | English |
| Funding | Patient (via insurance or gov’t) | Government |
| Unbreakable rule | Primum non nocere | Help underserved |
| View of EBM | Dictatorial | Magically improve patient care |
| Basis of Decision | Patient history, physical, tests | Risk, QALYs, etc. |
As a teacher of evidence-based medicine to residents, it was sometimes a hard sell. Once I started running a health center, I’ve realized it’s even harder.
One message for physicians is that it is not required to practice at the level of the evidence, but to know the level of evidence at which you’re practicing.
This does not sit well with policy types, managers or folks like Rich.
I am concerned that the misapplication of guidelines does not take into account patient priorities or realities. After all, they were not called protocols for a reason.
It is most important for care givers to stay abreast of trends and statistics that relate to the population in which they practise. Socitey has a changing makeup of ethnicities,ages and conditions.There is a changing set of conditions that are prevalent.
The patients ultimately depend on the caregivers knowledge and can benefit or suffer as a result.
http://www.healthfulview.com
What is meant by a process measure as opposed to an outcome. Is good diabetic, cholesterol, or blood pressure control an outcome or a process measure. Or is death and disability the outcome. If the latter, it will take a long time to come to any conclusion. How well a doctor does on most of the quality measures currently in use probably depends more on the educational level of his average patient than on his skill as a physician. To meet quality measures, the thing to do is to discharge from his practice all patients who can’t or won’t lose the weight or can’t or won’t take the amount of medicine necessary. Similar to teachers, for whom it is easy to show good test scores in an affluent suburban school where the students’ parents value education and are well-educated themselves. It is much more difficult to do so in a school whose students come from disorganized homes where their educations rank low on the family’s to-do list. Neither all medical practices nor all schools are near the mean in terms of the ability of the average member of their clienteles to do what is in his/her own best interest.