Afmc Primer on Population Health

AFMC primer on population health

September 12, 2017

12:54 PM

Chapter 1

1.1- Introduction: The widening scope of medicine

• Over the past half-century the Canadian population has seen unprecedented gains in longevity, health and well-being. We can now expect to live in out 80's, there is confidence in the system to treat previously untreatable diseases.
• There is also an expectation of faster access to health care in order to deliver these treatments
• Surprisingly the improvements in health have not reduced the demands on doctors, instead they are now expected o broaden heir scope of what they treat
• Though medical advances are good they also raise concerns over equity: since not everyone will be able to benefit equally from these improvements
• Second therapeutic innovations force us to consider the cost implications for a publicly funded, universal health care system.
• Third, as well as financial concerns there are also philosophical concerns of the broadening scope of care such as providing medical care to palliate avoidable problems such as obesity that arise from large measure from lifestyle focuses on social accountability
• The question arises: What conditions should doctors be expected and paid to treat and therefore how should they be trained

• In response the Royal College of Physicians and Surgeons of Canada published the CanMEDS framework in the 1990s to define competencies that physicians would need, and roles they should master, in providing the best quality of care in the new millennium
• The roles acknowledge that they are also expected to be competent as communicators, managers, health advocates, scholars and professionals
• A physician has now become an agent of health whose work involves treating patients and advocating for better policy, gate keeping health resources, attending conferences and engaging in research
• After many discussions over setting appropriate boundaries for medicine led to the thought that there is no agreed upon criteria for the definition of a disease
• The push of supply and the pull of demand have led us to classify more and more common conditions as disease ex. Viagra
• This broadening of the definition also has its disadvantages such as in the 1970's potential hazards were recognized by Ivan Illich, ex-priest, social critic and polemicist, in his discussion of ‘the morbid society.’

The Morbid Society

“Each civilization defines its own diseases. What is sickness in one might be chromosomal abnormality, crime, holiness, or sin in another . . . In a morbid society the belief prevails that defined and diagnosed ill-health is infinitely preferable to any other form of negative label or to no label at all. It is better than criminal or political deviance, better than laziness, better than self-chosen absence from work. More and more people subconsciously know that they are sick and tired of their jobs and of their leisure passivities, but they want to hear the lie that physical illness relieves them of social and political responsibilities. They want their doctor to act as lawyer and priest

1.2 Illness, sickness and disease

• What defines a disease is very complex, in 1973 Susser proposed some definitions that remain useful. T
• he used illness to refer to a subjective sense of feeling unwell; illness does not define a specific pathology, but refers to a person’s subjective experience of it, such as discomfort, tiredness, or general malaise.
• The way a patient reports symptoms is influenced by his or her cultural background, he then therefore applied the term "sickness" to refer to socially and culturally held conceptions of health conditions which in turn influences how the patient reacts
• Therefore the social perceptions of disease modify the ways a patient perceives and presents his symptoms
• Disease implies a focus on pathological processes that may or not produce symptoms and that result in a patients illness

• The 'biomedical model' of disease has dominated medical thinking, it focuses on pathological processes and on understanding, diagnosing and treating the physical biological aspects of disease
• The goal of treatment is to restore the patient's physiological integrity and function
• Diagnosis involves recognizing and applying a label to a pattern of signs and symptoms that is understood in terms of abnormal structure of function of cells, organs and functions.
• This offers a rational basis for the investigation of effective treatment

• Early biomedical conceptions supposed that a disease is either present or absent: a bacterium has invaded the body or not, but now its become apparent that there may not be a set threshold for defining disease.
• Thus instead of being seen as a state that is qualitatively distinct from health, many diseases have to be approached as a quantitative threshold on a continuum of biological variability

1.3 Disease or Syndrome?

• Often a set of signs and symptoms eludes biomedical understanding, if the set is frequent enough, it is termed a 'syndrome' instead of disease.
• A syndrome refers to a complex of symptoms that occur together more often than would be expected by chance alone.
• Diseases often receive explanatory labels(hemorrhagic stroke) whilst syndromes are given purely descriptive labels (restless leg syndrome)

1.4 Disease as a process: Natural History and clinical course

• The 19th century revolution led to the recognition of distinct stages in the development of disease
• If untreated a disease could evolve, but if an intervention is applied the natural history is modified, producing a clinical course for the condition
• After contact with an infectious agent there is a theoretical point where the disease process may begin

The Sequence of disease Outcomes

• International Classification of Impairment, Disability and Handicap (ICIDH), which proposed standard terms for the stages in the clinical course of a disease
• In this conception, pathology produces some form of disease and results in ‘impairment’, a deviation from normal function in an organ or system.
• Impairments are not always perceived by the patient, and screening tests are used to identify impairments of which the person is not aware. In turn, an impairment can, although does not necessarily, lead to a disability
• A disability is defined as “any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.
• ‘Handicap’ is defined as “a disadvantage for a given individual, resulting from an impairment or a disability, that limits or prevents the fulfillment of a role that is normal (depending on age, sex, and social and cultural factors) for that individual.
• Handicap relates the impact of a disease to the social roles of the person with it

The international Classification of Function

• In 2001, the WHO proposed more positive phrasing in terms of activities and abilities, resulting in the International Classification of Function, or ICF
• In other words, function is viewed as an interaction between a person’s health condition (such as a disease or injury) and the context in which he or she lives, including physical environment and cultural norms relevant to the disease

1.5 Definitions of Health

• In keeping with the biomedical perspective, early definitions of health focused on the theme of the body’s ability to function; health was seen as a state of normal function that could be disrupted from time to time by disease
• “a state characterized by anatomic, physiologic, and psychological integrity; ability to perform personally valued family, work, and community roles; ability to deal with physical, biologic, psychological, and social stress”
• Then, in 1948, in a radical departure from previous definitions, the WHO proposed a definition that aimed higher, linking health to well-being, in terms of “physical, mental, and social well-being, and not merely the absence of disease and infirmity

Health as a Resource

• new conception of health, not as a state, but in dynamic terms of resiliency, in other words, as “a resource for living”.
• The 1984 WHO revised definition of health defined it as “the extent to which an individual or group is able to realize aspirations and satisfy needs, and to change or cope with the environment
• new conception of health, not as a state, but in dynamic terms of resiliency, in other words, as “a resource for living”.
•  The 1984 WHO revised definition of health defined it as “the extent to which an individual or group is able to realize aspirations and satisfy needs, and to change or cope with the environment
• Health is a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social and personal resources, as well as physical capacities”.14 Thus, health referred to the ability to maintain homeostasis and recover from insults

Wellness

•  Wellness is “a word used by behavioral scientists to describe a state of dynamic physical, mental, social, and spiritual wellbeing that enables a person to achieve full potential and an enjoyable life
• Discussions of wellness eroded the hold of the biomedical model. In its place, ecological models of health appeared; these recognize the complex interactions among people, their personal characteristics and the environment, and how these influence health.
• This is a model of health and the community ecosystem that represents health determinants as concentric nested influences, beginning with the person at the centre (distinguishing body, mind, and spirit), then moving outwards to the social and physical environment, and then moving further out to culture, economic, and societal influences.

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Spiritual Health and Canadian Indigenous Healing Traditions

• The biomedical model hugely advanced our ability to treat the body but is somewhat less successful in treating the mind
• a challenge to the Cartesian way of thinking, First Nations, Inuit and Métis indigenous teachings have for a long time recognized other, non-physical dimensions of health
• Indigenous healing relationships are based on respect, humility, compassion, truth, sharing, hospitality, and divine love. They recognize more routes to healing than biomedical science, and the contrast highlights the dilemma facing modern physicians who aspire to provide health care when they often only have time to treat disease
• In recognition of the relevance of Indigenous concepts of health and healing, the Indigenous Physicians Association of Canada (IPAC) and the Association of Faculties of Medicine of Canada (AFMC) created a set of competency standards for medical students working with First Nations, Inuit, and Métis patients.
• The competencies are structured around the CanMeds physician roles; they are designed to train physicians to recognize the complexities of the historical relationship between indigenous and non-indigenous peoples, and how this complexity continues to affect the health care provided to indigenous people.

 Integrative Medicine

• ‘integrative medicine’25 as a collaboration between biomedical approaches and other healing traditions, including herbal remedies, manual interventions such as massage therapy or chiropractic, and mind-body practices such as hypnosis.

1.6 Public and Population Health

• “Public health is defined as the organized efforts of society to keep people healthy and prevent injury, illness, and premature death. It is a combination of programs, services, and policies that protect and promote the health of all Canadians
• population health is a relatively new concept, uncertainties remain over details of how, precisely, it differs from public health.
• The distinction is subtle, but population health is seen as broader, as offering a unifying paradigm that links disciplines from the biological to the sociological.
• When public health tackles a health issue, its interventions are focused on maintaining health or preventing disease A population health approach would tackle the disease in a broader context
• Public health focuses on prevention and health protection services, whereas the population health approach is somewhat broader. It still values “health” as a key outcome, but views issues from a broader perspective and tends to include additional considerations, such as economics, environmental sustainability, social justice, etc.

CHAPTER 2------------------------------------------------------------------------------------------------

2.1 Health Inequalities