Improving preventive care

[The authors respond:]

Dawna Gilchrist makes 2 arguments against the concept of preventive care in the acute care setting. Her first argument is that prevention is unlikely to make a difference among general internal medicine inpatients with multi-system disease. Gilchrist is overlooking the fact that the typical medical inpatient is, in fact, a person who stands to benefit the most from interventions such as influenza and pneumococcal vaccination. Likewise, individuals with comorbidities such as diabetes and chronic renal inefficiency are those who need the most careful monitoring and follow-up of their blood pressures. In addition, despite common belief, it is never too late to consider smoking cessation, as there are established benefits of smoking cessation that extend to geriatric patient populations. [1]

Her second argument is that even if it were worthwhile, it is too difficult for physicians to provide preventive care. She rightly points out that "preventive medicine is difficult to practise," particularly in the general internal medicine ward setting. Although we do not dispute that preventive care is a challenge to practising internists (who are often already stretched to the limit), we are not ready to dismiss a potential role for general internists in addressing the clear shortfalls in preventive care simply because it is "difficult." Rather, we proposed in our article that preventive care can be enhanced by general internists. [2] This view is shared by the Canadian Society of Internal Medicine in its assertion that disease prevention should be a focus of general internists because they often encounter acutely ill medical inpatients at a time when responsiveness to preventive interventions may be highest. [3]

The general sentiments conveyed in Gilchrist's letter highlight a fundamental challenge to those endeavouring to improve preventive care, and quality of care in general, in our health system. Many physicians and clinical care systems are already working at or near capacity. Care will only improve when we begin to develop resources and use technologies (e.g., physician extenders, computerized reminder systems) to assist physicians to expand their capacity.

William A. Ghali, MD, MPH

Richard Brull, MD

Hude Quan, MD, PhD

Departments of Medicine and Community Health Sciences; University of Calgary; Calgary, Alta.