Quaternary prevention

Prevention as you never heard before

Definitions of the four prevention fields as quoted in the

(publication in process)

Consider four fields in GP activity and consequently four types of prevention.
I: The patient is not sick and you are in a health promotion process or in immunisation campaign,
II: the patient is not sick and you are screening for diseases,
III: unfortunately you find the disease and now the patient knows that he is sick (but sometimes don't accept it),
IV: the last one, the fourth, is not the easiest, the patient feels himself sick and you find nothing or you was wrong in finding something.
Health promotion, screening and medical activities could throw the patient into the fourth field (Monday morning 'cardiac' patient after saturday evening TV panel on ischemic heart disease, cancerophobic women after anxiogenic repetitive mammography campaign, terrified patient about 3 mm liver angioma found in a routine abdominal scan, high PSA level patient with negative biopsies)

Consultation, a meeting between science and conscience is also a deal between patient and doctor anxiety. Quaternary prevention would raise the best way to protect the patient. Its also a Chi Square joke. How to deal with false positive?

Conscience or Patient feeling

well being

Science or Doctor knowledge, disease natural evolution
Absent ------------------------------------> Present
Primary prevention

Action taken to avoid or remove the cause of a health problem in an individual or a population before it arises. Includes health promotion and specific protection
(e.g. immunization)
Secondary prevention

Action taken to detect a health problem at an early stage in an individual or a population, thereby facilitating cure, or reducing or preventing it spreading or its long-term effects
(e.g. methods, screening, case finding and early diagnosis)
Quaternary Prevention

Quaternary Prevention: Action taken to identify patient at risk of overmedicalisation, to protect him from new medical invasion, and to suggest to him interventions, which are ethically acceptable.
Tertiary prevention

Action taken to reduce the chronic effects of a health problem in an individual or a population by minimizing the functional impairment consequent to the acute or chronic health problem
(e.g. prevent complications of diabetes). Includes rehabilitation.
This file edited in april 2000

Quaternary prevention is born in 1985 during a (boring) lecture on Chi Square. I had stopped temporarily my daily practice as general practitionner to follow a master in public health.
The first ever publication was in French in

Jamoulle M. Information et informatisation en médecine générale. [Computer and computerisation in general practice] in: Les informa-g-iciens.: Presses Universitaires de Namur; 1986:193-209
I have presented it at the WONCA congress in Hongkong :
Jamoulle M, (Wonca Classification committee), Roland M,(Equip Wonca Europe). Quaternary prevention and the glossary of general practice/family medicine, Poster, Hongkong Wonca congress proceedings, June 6/9, 1995
The concept of Quaternary prevention has been endorsed by the WONCA International Classification Committeee during its Durham meeting in 1999. The four definitions above are extracted from the WONCA dictionnary, edited by Niels Bentzen, OUP, 2000 (publication in process)

Some colleagues are walking on the same way :

Meador CK. The art and sciences of non disease. N.Engl. J. Med. 1965;272:92-95

Pilowsky I. Abnormal illness behaviour.Br J Med Psychol 1969 Dec;42(4):347-51

Grol R. (ed). To heal or to harm, the prevention of somatic fixation in general practice, Royal College of General Practitioners, London , 1981.

Snadden B. Ethical dilemmas of cervical cancer screening. Canadian family physician, 1992, 331-333

Hellstrom O W. Health promotion in general practice. Europ. J. Public Health. 1994;4:119-124

Guttman N, Kegler M, McLeroy KR. Health promotion paradoxes, antinomies and conundrums, Health education research,(editorial). (11) 1, march 1996; i-xii

Any suggestions?
Please feel free to send a mail or a copy of your publication by snail mail to this address;
Rue Frere Orban 94
B-6040 Jumet

Marc Jamoulle, MD, MPH
family doctor and researcher in Primary care