I think I’m going to have to start this post with a disclaimer: I am not a clinician. All my knowledge about medical education and practice has come from what I hear around me and the media, so if anything is wildly inaccurate, I apologise in advance!
Now, when a discussion around medicine and public health begins, it almost always ends up being the prevention vs treatment debate, but I’m not going to get into that here. Obviously prevention is a good idea, but we can’t prevent everything and the things we can prevent we can’t always prevent forever, so we need treatment just as much. There, that’s done – we need both.
I think it is generally accepted however that treatment and prevention are different things. Treatment is the domain of medicine – doctors and nurses applying their knowledge and skills, in conjunction with technology, in order to heal people and alleviate pain and suffering. Prevention, as I am using it, refers to the prevention of ill-health and suffering so that ideally, treatment isn’t needed: this is the role of public health. So really, when you think about it, medicine and public health are just two sides of the same coin – they both aim to improve people’s health, they just have different ways of going about it.
Despite this, there has been, and is, some tension between these two fields. I suspect these tensions are due to a difference in methods, as well as a difference in the level at which they work. I think from the public health side there is also a feeling that medicine as a discipline all but ignores public health. We all know that medicine aims to help individuals and public health aims to help populations, and I think that because different skills are needed for the two approaches, people believe they are two different subjects. i.e. the skills I need to improve the health of the one person standing in front of me are different to the skills I need to improve the health of 10,000 people standing in front of me.
Traditionally, public health is a speciality of medicine, where clinically trained doctors can choose to become a consultant in public health. My impression is that once doctors go down the public health route, their involvement in traditional clinical work diminishes, or maybe even stops. What I’m wondering is not why clinically trained public health consultants do so little clinical work, but why consultant doctors in other specialities do so little public health work?
Doctors have a pretty high social status in society. They are respected and are the most trusted profession in the UK. This link between doctors and high status is unsurprising given the conditions that humanity have lived in since the beginning of our existence. Until the second half of the 20th century, people often became ill from infections and injuries, which stopped them from carrying out their daily life and work. Doctors around the world have mostly learnt how to fix these things and therefore have been invaluable to society.
Due to that history of conditions, health systems have developed to treat these things, and 21st century health systems are still designed to deal most effectively with these infections and injuries, despite the largest burden of ill-health now coming from chronic, incurable conditions. This is not unexpected; re-designing a living breathing health system is no easy thing to do and I suspect it will take a little time before we come up with the right solutions for our change in health problems.
What I think is a little unexpected, is that the training of doctors doesn’t appear to me to have changed that much. Obviously doctors still need to treat infections and injuries in the same way: we have a pretty good way of killing pathogens and fixing broken human bodies, so there is no need to change that. I believe the issue is that the approach for treating communicable diseases has simply been applied to non-communicable conditions. This may have worked when they were small in number, but now that chronic conditions are in the majority, a different approach and thought process is needed – one that is not based on germ theory. I’m not about to start preaching to doctors about how to treat a myocardial infarction or subarachnoid haemorrhage, quite frankly, I have no idea. What I’m talking about is that I believe a wider approach is necessary for chronic conditions – one that is not based on just treating the person in front of you.
Before the development of germ theory, doctors believed that ‘miasma’ or ‘bad air’ caused many diseases, but no one knew for sure – this led physicians like John Snow to seek out other causes of disease, leading him to act on structural causes of disease, such as removing the handle of the Broad Street Pump to halt the cholera outbreak (outlined in the Wikipedia article if you don’t know this story). Once antibiotics were discovered however, doctors didn’t need to worry so much about how to prevent infections because now it was very easy to treat them. My impression is that this way of thinking has endured into the 21st century, but it doesn’t really work for non-communicable diseases. Doctors can put a stent in, or prescribe you aspirin after you have developed a chronic condition, but once you have developed it, you usually have to manage it for life, or a least manage a very big risk of having a another similar event that will take you to hospital. My basic point here is that doctors currently cannot permanently cure coronary heart disease, cancer, or the effects of a stroke once as person has these things – they can only mitigate and hope for the best. Now 21st century medicine is actually very good at mitigation, but it is only ever a stop-gap for many non-communicable diseases.
When it comes to something you can cure with tablets or an operation, maybe prevention can take second place. However, when you are dealing with a condition that can only be managed, and in reality, that managing is being done by the patient, how can treatment really be the best solution for that health problem overall? Prevention in this case is absolutely key if at the most basic level the aim of your job is to alleviate suffering and pain…isn’t it? Doctors will always help a person who already has a chronic condition, but for non-communicable diseases I believe they should also ask themselves how that person could have been prevented from developing a condition in the first place. When it comes to non-communicable diseases, doctors could help immensely more people if they were taught to consider the social and political effects on health as something doctors can also ‘treat’.
Many doctors are heavily involved in finding genetic treatments or cures for genetic conditions that are treatable and manageable, but not currently curable. This is unsurprising given that doctors seem to be mostly taught about the human body at a molecular level (bar anatomy?), but I get the impression that the social conditions the human body experiences, and its effects on physiology are not taught in as much detail. If the latter was taught, maybe more doctors would consider public health as part of the everyday role of all doctors.
Doctors are taught to treat the person in front of them, and of course they should do this, but when it comes to an incurable but preventable condition, why doesn’t medicine as a discipline teach doctors that stopping people from developing an incurable condition is better than treating and managing it for the rest of their life? Doctors practice what they are taught in medical school and in post-graduate training. If medical school teachers and curriculum developers can are willing to consider other approaches of alleviating ill-health, approaches that are not developed from germ theory, then in a decade’s time there could be thousands of doctors – people with high status and trust in society – who believe the best way to help someone who has a chronic condition is to make sure that they develop it as late in life as possible, or maybe even never.
So, maybe medical students are where public health should focus some of our efforts for chronic disease prevention. It certainly wouldn’t harm public health to have the full support of a major discipline that the public and politicians already associate with health and trustworthiness. Not to mention that public health would have a lot more people working towards the same goal.
So, maybe future medical students are the people who could help make public health accepted as a serious and high-status discipline?