460
Editorials
iorials
'New Habits of Mind'-Bridging the Gap Between Public Health and Clinical Medicine As RECENTLY AS 200 years ago medicine and surgery existed as separate spheres, without common training, collaborative practice, or substantive communication. An analogous chasm divides public health and clinical medicine to this day, despite decades of change in medical practice. Major efforts to promote research and education in the fields of preventive cardiology and pulmonary medicine have succeeded in modifying physicians' approaches to the identification and management of a variety of risk factors, have reduced risk-taking behaviors among much (though by no means all) of the general population, and have been accompanied by sharp declines in mortality from cardiovascular causes. Family practice and general internal medicine have incorporated clinical epidemiology and behavioral medicine into residency training and medical practice, so that questions about immunization status, sexual practices, substance abuse, and symptoms of depression now constitute good medical practice. Yet rates of measles, sexually transmitted diseases, murder, and adolescent suicide have risen, along with homelessness, lack of access to health care, underemployment, and unemployment. Public health officials, admittedly hampered by minuscule funding, have been no more successful and have limitations of their own. From Ellis Island to Tuskegee, Alabama, to Oregon, they have periodically detached themselves entirely from individual human beings, with appalling results. Physicians in clinical practice regard regulatory intervention and population study as alien activities. The admonitions of occupational medicine are often just one more voice faintly buzzing in the background. In this issue of the journal, Rosenstock and colleagues make themselves heard clearly. I They report the experience of the first ten years of an academic occupational medicine clinic firmly rooted in a department of medicine and in clinical practice. The clinic's three goals include diagnosing the work-relatedness of disease in individual patients, screening groups of workers for adverse health effects, and training physicians and other professionals (both generalists and specialists) in the field. It makes occupational and environmental medicine visible and accessible within traditional referral patterns: physicians in practice can pick up the phone and reach a colleague. Through the sheer force of will, these clinics have defined occupational medicine as an academic medicine specialty like cardiology or nephrology, only more so. Academicians wishing to recapture Osler's "art of observation ... [founded on] attention to subtle detail and unbiased assessment" can use occupational medicine: Listen to Sir Arthur Conan Doyle's description of the diagnostic skills of a contemporary Edinburgh surgeon: "Gentlemen," he would say to us students standing around, "I am not quite whether this man is a cork-cutter or a slater. I observe a slight callus, or hardening, on one side of his fourth finger and a little thickening on the outside of his thumb, and that is a sure sign that he is either one or the sure
other.'12(pW6)
Medical educators who find pure observational virtuosity too cold emphasize the need to maintain empathy and contact with a patient through history taking.3 Here, too, the occupa-
tional history can play a role in recognizing the patient as an adult and validating his or her abilities. Furthermore, the occupational history is a way of gaining insight into cultural, racial, and class diversity in an arena where some of the boundaries are shared. It fosters listening skills. It is not enough, however, to argue that occupational medicine adds to the clinical acumen and empathy of medical practitioners. The goal must be to merge clinical and public health traditions while recognizing individual areas of expertise. The easy access and flow of information provided by the academic occupational medicine clinics is a vitally important step. Equally important is establishing the prevalence of disease in at-risk populations, a function performed to some extent by the screening activities of the clinics. But clinics screen groups already known to be at risk from well-established hazards such as asbestos and do not provide population surveys on a scale necessary to address the issue of prevalence. Physicians in primary care practice see many patients with diarrhea, or irritability and depression, or Parkinson's disease, and evaluating all of them for organophosphate or lead or manganese poisoning is inappropriate. But what about subgroups at particular risk? Physicians need to know whether their patients are farm workers, construction workers, or welders and whether they have reentered sprayed fields or have done bridge-repair work recently. They can ask the patient and catch a glimpse of the patient's life that will be useful in establishing a therapeutic alliance. The sad truth is that once the exposure history has been obtained, the prevalence data that would make it meaningful do not exist. It is as if we were asked to evaluate a patient with chest pain without knowing the effects of age and sex. Physicians referred fully a quarter of the patients who were seen in this clinic for diagnostic purposes, but physician-referred patients were less likely than the clinic population as a whole to have occupationally related disease. In fact, patients referred by unions (10% ofthe total) were five times as likely to have occupational illness as patients referred by physicians. Demographics clearly play a part in this; unions generally refer from a population known to have an exposure, whereas physicians may be referring their diagnostic puzzles. I suspect that physician discomfort with the regulatory process may also be a factor not shared by referring unions. In both explanations, unions appear to be more comfortable than physicians with the public health aspects of occupational medicine. As a profession and as a society, we need to define the physician's role more broadly and set reasonable goals for practice. The Occupational Medical Practice Committee of the American College of Occupational and Environmental Medicine has attempted to do this. Their "scope of practice" guidelines include participation in developing governmental health and safety regulations as an essential component of practice, along with the diagnosis and treatment of occupational illness and the evaluation, inspection, and abatement of workplace hazards.4 While these define occupational and environmental medicine as a specialty, the framework they teach for viewing the role of physicians is useful. Regulation and abatement (enforcement) are legitimate areas of medical practice.
THE WESTERN JOURNAL OF MEDICINE * OCTOBER 1992 *
157 * 4
The absence ofadequate information about disease prevalence does not entirely exonerate practicing physicians. Their referral patterns should reflect some basic level of competency achieved during medical school or primary care residency training. Treating physicians evaluate exposure history and health outcome in patients and attempt to determine whether a biologically plausible connection can be made. This is a straightforward medical function, requiring physicians to use reference sources of information (including occupational medicine clinics) and to interpret uncertainty to their patients. The implications for false-positive as well as false-negative findings are substantial, particularly where nonoccupational environmental exposures are concerned. Anxiety about low levels of exposure may cause greater damage than the exposure itself, and some of these difficulties can be avoided by using basic pharmacologic principles regarding routes of absorption and dose-response relationships as well as positive criteria for alternative diagnoses. If a public health approach were added, students and practitioners would use new conceptual frameworks and an enlarged scope of resources rather than attempt to ingest yet one more set of facts. By introducing some of their basic tools, public health practitioners might offer clinicians an antidote for that classic source of workplace stress, responsibility without control. Borrowing again from work design models, increasing the diversity of tasks the worker (physician) is competent to handle might also enhance job satisfaction and prevent repetitive strain injuries (burnout?). Public health professionals benefit from clinical perspectives as well. Lung cancer in a 32-year-old is a sentinel event of a different order of magnitude than when it occurs in a 72year-old; regarding the "bullet as pathogen" may provide new insight into the root causes of violence in our society.' Occupational and environmental illness is one of many areas in which medicine and public health offer each other fresh approaches to education and practice. Maulitz describes the coming together of medicine and surgery in the wake of the French Revolution in terms that compel: But what happens when two [traditions], once in proximity but with disparate conceptions of health and disease, suddenly find themselves forced to make common cause? Precipitously, institutions and professional groups must grasp for means of accommodation. Intellectual resources must be discovered or created to help adjust to shifts in worldly resources. Covering explanations must be found. New habits of mind must be developed to permit the rupture and rethinking of old, exclusive roles and relationships. All of these things are accomplished through education and communication, through the assimilation and dispersion of symbols and ideas.6(Prn)
In the aftermath of the Cold War, perhaps we can do the same with clinical medicine and public health. ROSEMARY K. SOKAS, MD, MOH Associate Professor of Medicine Division of Occupational and Environmental Medicine
George Washington University Medical Center Washington, DC
REFERENCES 1. Rosenstock L, Daniell W, Bamhart S, et al: The 10-year experience of an academically affiliated occupational and environmental medicine clinic. West J Med 1992 Oct; 157:425-429 2. Belkin BM, Neelon FA: The art ofobservation: William Osler and the method of Zadig. Ann Intern Med 1992; 116:863-866 3. Spiro H: What is empathy and can it be taught? Ann Intern Med 1992; 116:843846 4. Perry GF, Clever LH, Ducatman AM, et al: Committee Report: Scope of Occu-
461 pational and Environmental Health Programs and Practice. J Occup Med 1992; 34:436-440 5. Adelson L: The gun and the sanctity of human life; or, the bullet as pathogen. Arch Surg 1992; 127:659-664 6. Maulitz RC: Morbid Appearances: The Anatomy of Pathology in the Early Nineteenth Century. New York, NY, Cambridge University Press, 1985
Complications of Asplenia and HyposplenismPersistent Uncertainties AFTER ONCE BEING CONSIDERED almost as unnecessary as the appendix, the spleen has been increasingly recognized in recent years as an important component of host defense against infection. This new-found respect is due in large part to the increasing appreciation ofthe syndrome of overwhelming postsplenectomy infection, especially its most characteristic presentation as fulminant septicemia-most often with an encapsulated organism such as Streptococcus pneumoniae and often without a discernible focus-with disseminated intravascular coagulation and multisystem dysfunction. In this issue Brigden provides a case history and literature review that illustrate many of the typical features of overwhelming postsplenectomy infection, including its sudden onset and rapid progression in an apparently healthy person and frequent progression to death despite intensive treatment.1 The inexorable downhill course of the patient described, despite vigorous treatment apparently within a few hours of initial symptoms, also highlights some of the many unresolved questions in predicting and preventing this devastating event. The uncontrollable nature of pneumococcal infection in this patient presumably reflects the loss of the contribution of the spleen to host-defense functions such as the filtration of particles from the blood stream and antibody and other opsonin production. Because these functions may be preserved to varying degrees in different situations, expectations and precautions for an individual patient depend on the highly imperfect information currently available to answer several questions. First, how common is overwhelming postsplenectomy infection? Second, who is at risk besides those with known removal of all splenic tissue, and can levels of risk be determined? Third, what measures are worthwhile for preventing overwhelming postsplenectomy infection, including the early treatment of suspected sepsis to avoid its progression to "overwhelming"? The absolute risk of fulminant infection in asplenic patients has been difficult to establish because of the lack of large cohort studies with consistent follow-up. A recent survey of events in an Australian population provides one of the larger groups thus far available, studied over a period designed to minimize the modifying effects of immunization and antimicrobial prophylaxis.2 This series yielded six late deaths from infection-although not all of these were categorized as overwhelming postsplenectomy infection-over 7,825 person-years of observation. Allowing for the exclusion of the immediate perioperative period, the resulting figure of 1 septic death per 1,305 person-years is within the range of a selection of earlier studies,3 but this selection tends to show wide variability, a higher incidence in infants and children, and variability according'to the reason for splenectomy. Situations short of documented splenectomy offer still fewer prospects for predicting risk. Congenital asplenia may
Editorials
iorials
'New Habits of Mind'-Bridging the Gap Between Public Health and Clinical Medicine As RECENTLY AS 200 years ago medicine and surgery existed as separate spheres, without common training, collaborative practice, or substantive communication. An analogous chasm divides public health and clinical medicine to this day, despite decades of change in medical practice. Major efforts to promote research and education in the fields of preventive cardiology and pulmonary medicine have succeeded in modifying physicians' approaches to the identification and management of a variety of risk factors, have reduced risk-taking behaviors among much (though by no means all) of the general population, and have been accompanied by sharp declines in mortality from cardiovascular causes. Family practice and general internal medicine have incorporated clinical epidemiology and behavioral medicine into residency training and medical practice, so that questions about immunization status, sexual practices, substance abuse, and symptoms of depression now constitute good medical practice. Yet rates of measles, sexually transmitted diseases, murder, and adolescent suicide have risen, along with homelessness, lack of access to health care, underemployment, and unemployment. Public health officials, admittedly hampered by minuscule funding, have been no more successful and have limitations of their own. From Ellis Island to Tuskegee, Alabama, to Oregon, they have periodically detached themselves entirely from individual human beings, with appalling results. Physicians in clinical practice regard regulatory intervention and population study as alien activities. The admonitions of occupational medicine are often just one more voice faintly buzzing in the background. In this issue of the journal, Rosenstock and colleagues make themselves heard clearly. I They report the experience of the first ten years of an academic occupational medicine clinic firmly rooted in a department of medicine and in clinical practice. The clinic's three goals include diagnosing the work-relatedness of disease in individual patients, screening groups of workers for adverse health effects, and training physicians and other professionals (both generalists and specialists) in the field. It makes occupational and environmental medicine visible and accessible within traditional referral patterns: physicians in practice can pick up the phone and reach a colleague. Through the sheer force of will, these clinics have defined occupational medicine as an academic medicine specialty like cardiology or nephrology, only more so. Academicians wishing to recapture Osler's "art of observation ... [founded on] attention to subtle detail and unbiased assessment" can use occupational medicine: Listen to Sir Arthur Conan Doyle's description of the diagnostic skills of a contemporary Edinburgh surgeon: "Gentlemen," he would say to us students standing around, "I am not quite whether this man is a cork-cutter or a slater. I observe a slight callus, or hardening, on one side of his fourth finger and a little thickening on the outside of his thumb, and that is a sure sign that he is either one or the sure
other.'12(pW6)
Medical educators who find pure observational virtuosity too cold emphasize the need to maintain empathy and contact with a patient through history taking.3 Here, too, the occupa-
tional history can play a role in recognizing the patient as an adult and validating his or her abilities. Furthermore, the occupational history is a way of gaining insight into cultural, racial, and class diversity in an arena where some of the boundaries are shared. It fosters listening skills. It is not enough, however, to argue that occupational medicine adds to the clinical acumen and empathy of medical practitioners. The goal must be to merge clinical and public health traditions while recognizing individual areas of expertise. The easy access and flow of information provided by the academic occupational medicine clinics is a vitally important step. Equally important is establishing the prevalence of disease in at-risk populations, a function performed to some extent by the screening activities of the clinics. But clinics screen groups already known to be at risk from well-established hazards such as asbestos and do not provide population surveys on a scale necessary to address the issue of prevalence. Physicians in primary care practice see many patients with diarrhea, or irritability and depression, or Parkinson's disease, and evaluating all of them for organophosphate or lead or manganese poisoning is inappropriate. But what about subgroups at particular risk? Physicians need to know whether their patients are farm workers, construction workers, or welders and whether they have reentered sprayed fields or have done bridge-repair work recently. They can ask the patient and catch a glimpse of the patient's life that will be useful in establishing a therapeutic alliance. The sad truth is that once the exposure history has been obtained, the prevalence data that would make it meaningful do not exist. It is as if we were asked to evaluate a patient with chest pain without knowing the effects of age and sex. Physicians referred fully a quarter of the patients who were seen in this clinic for diagnostic purposes, but physician-referred patients were less likely than the clinic population as a whole to have occupationally related disease. In fact, patients referred by unions (10% ofthe total) were five times as likely to have occupational illness as patients referred by physicians. Demographics clearly play a part in this; unions generally refer from a population known to have an exposure, whereas physicians may be referring their diagnostic puzzles. I suspect that physician discomfort with the regulatory process may also be a factor not shared by referring unions. In both explanations, unions appear to be more comfortable than physicians with the public health aspects of occupational medicine. As a profession and as a society, we need to define the physician's role more broadly and set reasonable goals for practice. The Occupational Medical Practice Committee of the American College of Occupational and Environmental Medicine has attempted to do this. Their "scope of practice" guidelines include participation in developing governmental health and safety regulations as an essential component of practice, along with the diagnosis and treatment of occupational illness and the evaluation, inspection, and abatement of workplace hazards.4 While these define occupational and environmental medicine as a specialty, the framework they teach for viewing the role of physicians is useful. Regulation and abatement (enforcement) are legitimate areas of medical practice.
THE WESTERN JOURNAL OF MEDICINE * OCTOBER 1992 *
157 * 4
The absence ofadequate information about disease prevalence does not entirely exonerate practicing physicians. Their referral patterns should reflect some basic level of competency achieved during medical school or primary care residency training. Treating physicians evaluate exposure history and health outcome in patients and attempt to determine whether a biologically plausible connection can be made. This is a straightforward medical function, requiring physicians to use reference sources of information (including occupational medicine clinics) and to interpret uncertainty to their patients. The implications for false-positive as well as false-negative findings are substantial, particularly where nonoccupational environmental exposures are concerned. Anxiety about low levels of exposure may cause greater damage than the exposure itself, and some of these difficulties can be avoided by using basic pharmacologic principles regarding routes of absorption and dose-response relationships as well as positive criteria for alternative diagnoses. If a public health approach were added, students and practitioners would use new conceptual frameworks and an enlarged scope of resources rather than attempt to ingest yet one more set of facts. By introducing some of their basic tools, public health practitioners might offer clinicians an antidote for that classic source of workplace stress, responsibility without control. Borrowing again from work design models, increasing the diversity of tasks the worker (physician) is competent to handle might also enhance job satisfaction and prevent repetitive strain injuries (burnout?). Public health professionals benefit from clinical perspectives as well. Lung cancer in a 32-year-old is a sentinel event of a different order of magnitude than when it occurs in a 72year-old; regarding the "bullet as pathogen" may provide new insight into the root causes of violence in our society.' Occupational and environmental illness is one of many areas in which medicine and public health offer each other fresh approaches to education and practice. Maulitz describes the coming together of medicine and surgery in the wake of the French Revolution in terms that compel: But what happens when two [traditions], once in proximity but with disparate conceptions of health and disease, suddenly find themselves forced to make common cause? Precipitously, institutions and professional groups must grasp for means of accommodation. Intellectual resources must be discovered or created to help adjust to shifts in worldly resources. Covering explanations must be found. New habits of mind must be developed to permit the rupture and rethinking of old, exclusive roles and relationships. All of these things are accomplished through education and communication, through the assimilation and dispersion of symbols and ideas.6(Prn)
In the aftermath of the Cold War, perhaps we can do the same with clinical medicine and public health. ROSEMARY K. SOKAS, MD, MOH Associate Professor of Medicine Division of Occupational and Environmental Medicine
George Washington University Medical Center Washington, DC
REFERENCES 1. Rosenstock L, Daniell W, Bamhart S, et al: The 10-year experience of an academically affiliated occupational and environmental medicine clinic. West J Med 1992 Oct; 157:425-429 2. Belkin BM, Neelon FA: The art ofobservation: William Osler and the method of Zadig. Ann Intern Med 1992; 116:863-866 3. Spiro H: What is empathy and can it be taught? Ann Intern Med 1992; 116:843846 4. Perry GF, Clever LH, Ducatman AM, et al: Committee Report: Scope of Occu-
461 pational and Environmental Health Programs and Practice. J Occup Med 1992; 34:436-440 5. Adelson L: The gun and the sanctity of human life; or, the bullet as pathogen. Arch Surg 1992; 127:659-664 6. Maulitz RC: Morbid Appearances: The Anatomy of Pathology in the Early Nineteenth Century. New York, NY, Cambridge University Press, 1985
Complications of Asplenia and HyposplenismPersistent Uncertainties AFTER ONCE BEING CONSIDERED almost as unnecessary as the appendix, the spleen has been increasingly recognized in recent years as an important component of host defense against infection. This new-found respect is due in large part to the increasing appreciation ofthe syndrome of overwhelming postsplenectomy infection, especially its most characteristic presentation as fulminant septicemia-most often with an encapsulated organism such as Streptococcus pneumoniae and often without a discernible focus-with disseminated intravascular coagulation and multisystem dysfunction. In this issue Brigden provides a case history and literature review that illustrate many of the typical features of overwhelming postsplenectomy infection, including its sudden onset and rapid progression in an apparently healthy person and frequent progression to death despite intensive treatment.1 The inexorable downhill course of the patient described, despite vigorous treatment apparently within a few hours of initial symptoms, also highlights some of the many unresolved questions in predicting and preventing this devastating event. The uncontrollable nature of pneumococcal infection in this patient presumably reflects the loss of the contribution of the spleen to host-defense functions such as the filtration of particles from the blood stream and antibody and other opsonin production. Because these functions may be preserved to varying degrees in different situations, expectations and precautions for an individual patient depend on the highly imperfect information currently available to answer several questions. First, how common is overwhelming postsplenectomy infection? Second, who is at risk besides those with known removal of all splenic tissue, and can levels of risk be determined? Third, what measures are worthwhile for preventing overwhelming postsplenectomy infection, including the early treatment of suspected sepsis to avoid its progression to "overwhelming"? The absolute risk of fulminant infection in asplenic patients has been difficult to establish because of the lack of large cohort studies with consistent follow-up. A recent survey of events in an Australian population provides one of the larger groups thus far available, studied over a period designed to minimize the modifying effects of immunization and antimicrobial prophylaxis.2 This series yielded six late deaths from infection-although not all of these were categorized as overwhelming postsplenectomy infection-over 7,825 person-years of observation. Allowing for the exclusion of the immediate perioperative period, the resulting figure of 1 septic death per 1,305 person-years is within the range of a selection of earlier studies,3 but this selection tends to show wide variability, a higher incidence in infants and children, and variability according'to the reason for splenectomy. Situations short of documented splenectomy offer still fewer prospects for predicting risk. Congenital asplenia may
