Response: Re: Improving Performance in Prevention

To the Editor: Definitions are critical. I have used the distinction the World Health Organization and many other authors use. Primary prevention is directed at avoiding the development of disease by targeting risk factors such as smoking, diet, or number of sexual partners. Secondary preventive care such as Papanicolaou smears and colonoscopy is aimed at early disease detection, with the goal of preventing progression of the disease. Tertiary prevention reduces the adverse effects of an already established disease: clinical examples include retinal screening for diabetics or β blockers after myocardial infarction.

With these definitions in mind, I would argue that family physicians are involved at all levels of prevention. Almost all family physicians counsel about exercise and lipids, take Papanicolaou smears and blood pressures, and give diabetics statins and eye exams. Although there is obviously a major role for traditional public health—not just in sanitation but in promotion of healthy lifestyles—we should acknowledge and celebrate the key role that family physicians and other primary care providers play in prevention. This is particularly true in postindustrial society in which chronic disease represents an increasing component of our health challenges. What family physicians do has a substantial impact on public health. Is prevention in clinical care easy? No. Is is well reimbursed? Not really, but much better than it used to be. Can we organize our practices to be more effective in prevention? That is the focus of the Oklahoma study, and why it is important.

Finally, about Aesclepius’ tortured family: as always, the Greeks have much to teach us. The author's concerns regarding commercial influence in medicine and comment regarding the tension between prevention and treatment are well taken. I would argue, however, that the history has another very important lesson: the mythical father of medicine encompasses not only prevention (Hygeia) and curing (Panacea), but also healing (Iaso) and surgery (Aesclepius’ sons, Podaleinious and Machaon). All are important.