Building A Fund of Knowledge for Community Medicine

It is a safe rule to have no teaching without a patient for a text,and the best teaching is that taught by the patient himself.

- Sir William Osler

Mattie

• 67-year-old African American female

• Long history of type 2 diabetes

• Admitted with progressive shortness of breath

• Evaluated appropriately with history, physical exam, lab, x-ray, echocardiogram

• Silent myocardial infarction and congestive heart failure

Mattie, continued

• From a CV standpoint, she did well

• Blood sugars were poorly controlled

• “Non-compliant”

Mattie’s Vices

ADA Diet, Board Exam Prep

• Which of the following would NOT be considered the most healthful food choices for an individual with type 2 diabetes?

A. Fresh fruits and vegetables

B. Dried beans

C. Fatback and buttermilk

D. Whole grain foods

We don’t always tell the truth.

We don’t always know the truth.

The Truth

ABCs of Preventive Cardiology

• A – Aspirin/antiplatelet; ACE

• B – Beta blocker

• C – Cholesterol; cigarettes

• D – Diabetes;

• E – Vitamin E; Estrogen; Exercise

ABCs of Preventive Cardiology

• A – Aspirin/antiplatelet; ACE/ARB

• B – Beta blocker

• C – Cholesterol; cigarettes

• D – Diabetes;

• E – Vitamin E; Estrogen; Exercise

We don’t always tell the truth.

We don’t always know the truth...

The Truth

Yet!

Aristotle’s Intellectual VirtuesWays of Knowing

• Techne

• Sophia• Episteme

• Phronesis

• Nous

Quality of Evidence

• Level I: Evidence obtained from at least one properly designed randomized controlled trial.

• Level II-1: Evidence obtained from well-designed controlled trials without randomization.

• Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

• Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

• Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

The Scientific Method

• Experience: start from observation

• Conjecture: formulate hypothesis

• Prediction: reasoning from hypotheses

• Experiment: testing these elements

Characteristics

• External

• Third person

• Dispassionate

• I-It

Classic Experimental Design

Pre- Intervention Post-

Experimental

GroupO X O

Control

GroupO O

Challenges of Communities

• Complex organisms

• Chaotic

• Non-linear

People are Messy!

Simple Complex

Rigorous

Not so much

?

How do we embrace

a broader range of ways

to generate new knowledge,

while still retaining rigor?

Anxiety about “Community”

• Focus?– Primary care– Indigent

• Imagery

• Content– Community college?

The “Honors College”A Value-Added Curriculum

• Traditional biomedical curriculum

• Biopsychosocial model

• Public health themes/content

Community MedicineFrom Molecule to Culture

Molecule

Public Health Disciplines

• Biostatistics

• Epidemiology

• Health Administration and Policy

• Health Promotion Sciences

• Occupational and Environmental Health

Certificate in Public Health

• Biostatistics

• Epidemiology

• Social and Behavioral Sciences in PH

• US Health Care Systems

• Environmental Health

• Integrated Public Health Practice

Who Will Keep the Public Healthy?

• Epidemiology• Biostatistics• Environmental health• Health services

administration• Social and behavioral

sciences• Informatics

• Genomics• Communication• Cultural competence• Community-based

participatory research• Global health• Policy and law• Ethics

Training Physicians forPublic Health Careers

• Leadership

• Public health emergency preparedness

• Clinical and community preventive service provision

• Across contiunuum of medical education

• Regardless of specialty

Medicine is the most humane of sciences, the most empiric of arts, and the most scientific of humanities.

- Edmund PellegrinoHumanism and the Physician

Re-visiting Mattie

• How would the perspective of a provider trained in community medicine enhance her care?

• How have or can public policy and public health practice impact her care?

Outside the doctor-patient relationshipthere is a wider placefilled with community. And it calls to usthrough the voice of public health.

- Author unknown