Doctor support critical in the fight for community prevention

by Larry Cohen

When Florida Governor Rick Scott recently signed legislation barring doctors from asking about gun safety practices in the homes of their child patients, it sounded the alarm that physicians’ roles in community prevention are chronically misunderstood. Rather than restricting doctors’ options for involvement in prevention, we should be supporting and expanding them.

Community prevention is the creation of physical and social environments that support safe, healthful lives so that people don’t get sick and injured in the first place. The term covers a diverse set of measures, ranging from macro-level policies like including more fresh foods in school lunches, to community-level solutions like designing streets that support bikers and pedestrians, or engaging youth in extracurricular activities to prevent violence or drug abuse. Part of the challenge for community prevention advocates is that these critical solutions have not been integrated into conversations on health care, though they have a huge impact on our health.

Studies indicate that behavior and environment account for roughly 70% of our health outcomes. Genetics account for 20% and medical care, 10%. Yet 96% of our national health expenditures are focused on medical care, with only 4% dedicated to prevention. We have learned that our growing medical expenditures are not helping to stem the rapid growth of chronic disease in America, the cost of these illnesses to our economy, or the burden of these illnesses on our health care system. Prevention is part of the answer.

Doctors are skilled and experienced in some kinds of prevention—immunizations, wellness exams, and early detection of illness through screenings like mammograms, to name a few. But physicians are also critical and natural allies in the fight for community prevention. In fact, the skills needed to engage in community change are closely aligned with the problem solving skills doctors currently employ to address individual health needs. With patients, physicians follow a three-part process: collect data (symptoms, vital signs, tests, etc.), diagnose the problem, and develop a treatment plan.

These same skills can be applied to communities if clinics collect data on local health trends, review them periodically to determine root causes, and then support efforts to improve those conditions. Innovative approaches like these are already in use at St. John’s Well Child and Family Center in Los Angeles, where doctors engaged in community change after noting an increase in illness and injury related to substandard housing conditions. The clinic collaborated with other community leaders to secure local administrative policies and agreements that have improved landlord compliance with housing standards.

Doctors at St. John’s and other pioneers recognize that in order to comply with “doctor’s orders,” patients need supportive places to live, work, learn, and play. It would be difficult for someone to take his recommended daily walk when the nearest park is in the next city and his local sidewalks are in disrepair. A working mother of two won’t find fresh vegetables at a local corner store, but what where else can she shop if no grocery stores will open in her neighborhood?

America has a proud and successful history of physicians spearheading primary prevention measures because Americans regard them as the foremost authorities on health. Tired of treating injured infants, Tennessee pediatrician Dr. Robert Sanders pioneered the child safety seat law that paved the way for all states to reduce death and injury from motor vehicle crashes. Doctors’ expert testimony also played an important role in passing regulations that have significantly decreased smoking since 1965. Doctors are on the front lines, and their vigilance and expertise are essential to bolstering community prevention and incorporating it into American healthcare.

So how can we create more opportunities for clinicians to engage with primary prevention? It must start early on in training our future doctors. Simple changes, like the case studies chosen for review, can expose medical students to prevention thinking without adding bulk to a full curriculum. Schools like the University of California, San Francisco already use case studies that profile the patient’s family and neighborhood, teaching students to identify social and environmental factors that contribute to the patient’s illness or injury. These readings can be supplemented with opportunities to attend community meetings to learn the social and environmental context of what they’re seeing in the clinic. When community advocates and physicians work together to expand the American definition of health care, we can better prepare to face current and projected challenges to our health and safety.

Larry Cohen is founder and Executive Director of Prevention Institute, a national non-profit dedicated to improving community health and equity through effective primary prevention: taking action to build resilience and to prevent illness and injury before they occur.

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  • Sharon Dietrich

    Talking with our patients about gun safety at home is just one of the preventative items we talk about during Well Child Care, for example. We talk about safe cribs, sleeping positions for infants, bike helmets, using seat belts, after school activities, smoking, drugs, alcohol, to name a few. The decision by Florida’s governor is politics(read NRA) over safety and common sense. Obviously, we need to educate some folks in government as to our role is individual, family, and community health and prevention!!

  • Tim Richardson

    Rick’s Scott’s decision has less to do with doctors and more to do with gun rights – I second Ms. Dietrich’s opinion above. This is an NRA issue that was waiting in the wings. After the Tea Party victory in November the Florida legislature shifted to overwhelmingly Republican and many extreme right wing freshmen.

    The Far Right wants to prevent ANY interference from the government (including pediatricians asking standardized questions) that might interfere with their right to owm and carry a firearm.

    Scott just signed what the Legislature passed.

    Interestingly, on the exact same day (within hours) of signing “Docs and Glocks” Governor Rick Scott also signed a new LAW banning people from wearing baggy pants with their underwear showing!

    It seems the Far Right thinks its OK for the government to enforce a dress code but not to restrict firearms.



  • buzzkillersmith

    Say what? Docs can’t ask about firearms in Florida? If that is really true, it is totally nuts.

    • pj

      You must not watch much news on TV… not that it’s generally helpful to do so.
      It is true. Seems as nuts as electing Scott to begin with.

  • Frank in L.A.

    When I see my physician I am not going there to see a nanny.

    If those physicians in Florida intruding into areas of their patient’s life in which they have no business would realize this, then Florida would not have had dumb laws like the gun question law.

  • Hexanchus

    Sigh….here we go again…..

    The subject of Florida’s HB155 has already been thoroughly discussed in at lease two threads, most recently in a post by Dr. James Logan.

    You folks might want to get your facts straight. This bill was not a part of a NRA or Tea Party agenda. It came about because of the actions of a physician who fired a patient for refusing to answer when questioned about gun ownership. The constituent then complained to their elected representatives and ultimately HB155 was the result. The doctor asking the question in the first place was doing so as part of a political anti-gun agenda promoted by a physicians organization, and it blew up in their face.

    Was it a knee jerk reaction? Absolutely!
    Does it serve the best interests of patients and physicians? No, not really.

    But then again, neither does the over the top action of the physician in firing the patient for refusing to answer a question that is not directly related to medical care. Quite frankly, it’s none of the physician’s business, and certainly should not be part of a medical record. The physician does not have any “right” to that or any other information. In fact, the only information a physician is entitled to is that which the patient chooses to share with them.

    I submit that the vast majority of physicians are likely unqualified to offer meaningful education on firearm safety. Instead of asking questions they’re most likely not qualified to answer, how about they simply offer all patients a pamphlet on where to obtain legitimate firearm safety instruction if they are interested and leave it at that. Ironically, the most proactive promoter of firearm safety is the NRA – the organization you are so quick to vilify.

    As one commenter put it in reply to Dr. Logan’s article, both the pro and anti gun factions need to stay the hell out of the doctor patient relationship.

    Mr. Cohen makes the statement “Doctors at St. John’s and other pioneers recognize that in order to comply with “doctor’s orders,” patients need supportive places to live, work, learn, and play.” I find this attitude highly paternalistic, and I’ve got news for you – paternalism in medicine is dead – may it eternally rest in peace! Doctors are in no position to “order” a patient to do anything, legally or ethically. Health care is a partnership that can only truly succeed in an environment of mutual trust and respect. Physicians need to encourage their patients to become active participants in their health care, and work together with them to develop and agree on a course of action, be it prevention or treatment.

    • Marc Gorayeb, MD

      Agreed. We should all be free to speak, to ask, and to refuse to reply. Physicians should not be free to terminate a patient because the patient chooses to exercise this basic freedom. It is idiotic and unprofessional to expect your patients to always be completely truthful with you, or not to occasionally hold back information. Where was the state medical board on this physician’s behavior? Had they been appropriately sanctioned, the legislature likely would not have become involved.

      • ninguem

        What Hexanchus said.

        What has been said over and over again, over, and over, and over, and over, and over……….

        This legislation didn’t come up out of thin air. Busybodies came in from the antigun side. This is a reaction to one of many incidents like the one Haxanchus described.

        Once again, until it sinks in…..both the pro and anti gun factions need to stay the hell out of the doctor patient relationship.

        I’ll quibble with Marc over the physicians right to terminate a patient. They should remain free to terminate for any reason or no reason.

        Even a stupid reason.

        When the antigun forces nosed into the physican-patient relationship, sure as night follows day, the antigun forces now have a reason to nose into the physician-patient relationship.

        The result of this, someday there will be a patient with depression, homicidal or suicidal thoughts, where knowing about the firearms indeed becomes a good thing to know.

        Now the doctor faces a roadblock to getting information that’s really needed.

  • pj

    Sad thing is, preventive medicine, as a field at least, is being starved in america. Not only are PM residency programs shutting down, I can’t get all the job offers I would if I were a family practice residency trained Doc. Even though PM is a huge part of FP, patients and insurers don’t seem to recognize this.

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