Family Medicine

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World Book of Family Medicine – European Edition 2015 family doctors to patients' rights. Aten Primaria 2007;39(1):23-8. Spanish. 4. Parsapoor A, Mohammad K, Malek Afzali H, Ala'eddini F, Larijani B. Observance of Patient's Rights: A Survey on the Views of Patients, Nurses, and Physicians. J Med Ethics Hist Med. 2012 2;5:5. 5. Di Matteo MR, Sherbourne CD, Hays RD, Ordway L, Kravitz RL, McGlynn EA, et al. Physicians’ characteristics influence patients’ adherence to medical treatment: results from the medical outcomes study. Health Psychol. 1993;12:93-102. 6. DeVoe J, Fryer Jr GE, Hargraves JL, Phillips RL, Green LA. Does career dissatisfaction affect the ability of family physicians to deliver high-quality patient care? J Fam Pract 2002;51(3):223-8. 7. Beach MC, Duggan PS, Cassel CK, Geller G. What does ‘respect’ mean? Exploring the moral obligation of health professionals to respect patients. J Gen Inter Med 2007;22:692-5. 8. Dickert NW, Kass NE. Understanding respect: learning from patients. J Med Ethics 2009;35:419-23. 284
World Book of Family Medicine – European Edition 2015 Marc Jamoulle, MD marc.jamoulle@doct.ulg.ac.be 93 – About Quaternary Prevention: First, Do No Harm. Marc Jamoulle, MD Family doctor, Department of General Practice, University of Liege, Belgium Wonca International Classification Committee & Wonca Informatics Working Party Member Towards patient-doctor relationship-based care Clinical prevention, under the influence of public health, has been organised in a chronological manner since the middle of the 20th century. A paradigm shift from a chronological to a constructivist relationship-based preventive pattern of care (1) offers new insight into the practice of doctors, and brings to light the concept of quaternary prevention, a critical look at medical activities with an emphasis on the need not to harm. Quaternary prevention addresses the fundamental question of what constitutes too much or too little medicine. It is the fourth form of disease prevention, but also the fourth frame of action for family doctors. Figure 1. Four fields of the patient-doctor encounter based on relationships. The doctor looks for diseases. The patient could feel ill. Timeline is obliquely oriented from left to right, from alpha to omega, from birth to death. Anyone will become sick and die, doctors as well as patients (Jamoulle 1986). The shift from time-based prevention towards a relationship-based organisation offers new perspectives into a physician’s work. He or she observes him- or herself, and questions the ethical limits of their activities. In this sense, quaternary prevention is aimed more at the doctor than the patient. Moreover, the four definitions of prevention published in the WONCA Dictionary of Family Medicine (2) offer a structured way to discuss the activities of family doctors, including ethical considerations on the patient-doctor encounter. Quaternary prevention, also known as P4, is a new term for an old concept: first, do not harm. This concept enforces disciplines and attitudes such as evidence-based medicine, quality assurance, defensive medicine, avoiding abusive nosographic diagnoses and ethical issues including those linked to a heartsink patient. 285
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Family Medicine

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