Is there a discipline of community medicine?

Is There a Discipline of Community Medicine?

PHILIP W. BRICKNER, M.D. New York, New York

It is time to consider whether Community Medicine is an identifiable discipline, or merely a fad of the 1960’s and 70’s [ 11. Does it really exist or is it the “nuciform sac” [2] of the present day? For Community Medicine to assume the stature of a distinct discipline the following qualifications must be met: (1) Community Medicine derives from recognizable medical origins; (2) it is subject to a clear definition and is distinguishable from other academic/clinical fields; and (3) it creates opportunities for patient care, teaching and research which are unique. The field of Community Medicine amply fulfills these qualifications. MEDICAL ORIGINS Discussion about Community Medicine has tended to stress its innovative quality, radical nature and revolutionary character, “as if it had derived from a recent birth of new ideas and concepts” [3]. It is true that the birth rate of Departments of Community Medicine in the last 15 years has been high [4]. A cynical interpretation of this fact might lead us to believe that hospitals and medical schools have created a new field, and established these units merely as a response to the political and community pressures of the time [5]. In fact, however, the field of Community Medicine as we know it today, and as defined herein, is the product of a prolonged evolutionary process. The origins of community-oriented medicine are multiple and diverse. Key sources include, for example, Edward Jenner’s development of cowpox vaccine as a public health measure against smallpox [6,7] and the control of yellow fever by elimination of the Aedes aegypti mosquito from Cuba and the Canal Zone [8]. We find traces in the rites of prechristian preventive medicine: The one who bears the sore of leprosy shall keep his garments rent and his head bare, and shall muffle his beard; he shall cry out, “unclean, unclean!” As long as the sore is on him he shall declare himself unclean . . . . He shall dwell apart, making his abode outside the camp [9].

From

the

Department of Community Medicine,

saint Vincent’s Hospital and Medical Center of New York, New York. Requests for reprints should be addressed to Dr. Philip W. Brickner, Saint Vincent’s Hospital, 153 West 1 lth Street, New York, New York 10011. Manuscript accepted October 31, 1975.

936

In the industrialized world, the great health advances of the last 100 years have come from social and hygenic reform, ancestors of Community Medicine, rather than from the orthodox medicine of the time. This is demonstrated, for example, by the decline in the incidence of typhoid fever and cholera in England during the late 19th century, following improvement in the purity of the water supply and despite the lack of specific medical treatment for these diseases [ lo]. Recognition of this point is in part responsible for the growth of cadre of physicians who, in this country and this century, have developed a wider view of the role of a doctor. As Abraham Flex-

a

ner pointed out in 19 10:

June 1976 The American Journal of Medicine Volume 60

iS -HERE

It is hardly too much to say that modern hygiene, largely the outcome

of bacteriology,

from a mainly personal

has elevated the physician

to a mainly social status.

Directly

or indirectly,

disease has been found to depend largely on unpropitious environment. A bad water-supply, defective drainage, impure food, unfavorable occupational surroundings-matters, all of them, for social regulation,-at once harbor our parasitic enemies and reduce our powers of resisting them [ 1i] Community

Medicine

its multiple

medical

as we know

origins.

it today

Departments Preventive

reflects of Public Medicine

Health, Social Medicine, [ 12,131 and Ambulatory Care are its immediate genitors.

pro-

DEFINITION Community

Medicine

the general

health

is defined

by its concern

of the population

with

at large; and the

needs of people who lack access to the system of medical care [ 14,151. Community Medicine encompasses all services and programs that affect the community’s health. The technics of examination, diagnosis, treatment and evaluation apply communities and individual people [ 161. In practice, the structure of Community

equally

to

The highly academic programs emphasize pedagogic material and attempt to define Community Medicine as though it were a part of the traditional medical curriculum. The following subjects have been cited as the basic sciences of Community Medicine: epidemiology, demography, biostatistics, organization and administration of medical care, behavioral and social sciences, operations research, systems evaluation medicine

A proponent

technics, cost-benefit and health education

analysis, methods

of this view states:

The specialist in community medicine is mainly concerned with populations and their health characteristics and needs rather than with individual patients. His contributions

should

interpretation health,

be concerned of

trends

the evaluation

of patient

of

care, the design

and operational

with the measurement the

various

of the effectiveness

studies,

parameters

priorities, and the development ning of new resources [ 191.

of

of clinical

of objectives

of existing

and

of all aspects

and interpretation

the definition

projects

centers

and

and the plan-

The ultimate consequence of this skewed definition is the development of physicians who are involved with the “community” but not with the people in it. At the other extreme is a definition of Community Medicine based solely on program. Free clinics,

OF COMMUNITY

for skid-row

for homosexuals

MEDICINE?-BRICKNER

men,

venereal

and similar

disease

ventures

con-

ducted by volunteer health workers, have with few exceptions [20,21] demonstrated limited staying power. Most have failed; and the failures are due not to the

lack

of need

but to inadequate

community

base, the inherent evils of volunteerism, the emphemeral nature of government and other funding sources, and/or the failure to provide adequate backup support care institutions The preferred

through affiliation with major health [ 14,22-261. definition of Community Medicine is

founded upon the basic sciences icine and includes a substantial

of Community Medelement of patient

contact as well. It is a good mix of the theoretic and the real. As is true of all sound fields in medicine, Community Medicine is a scientific attack upon a set of practical problems [27]. Community Medicine does not focus on a particular organ system or age group. Instead, it devotes its attention to the application and integration of many health disciplines to the needs of the community. Departments of Community Medicine regularly include

Medicine

programs in the United States spans a wide range, from strictly education and research-directed schools at one extreme, to pure patient care clinics at the other [ 4,171.

analysis, preventive [17,18].

health

A DISCIPLINE

internists,

pediatricians,

family

practitioners,

nurses, social workers, nutritionists, epidemiologists and biostatisticians. The Community Medicine Department is the unit within an institution which seeks community contact rather than shunning it. Information about the social and health status of community people and groups, their attitudes and motivation, is made available through this Department. analysis and interpretation: the definition of objectives nity health velopment tegrated

The data are subject to and are utilized in turn for and priorities in commu-

care, the study of etiologies and the deof resources [ 191. This information is in-

into a practical

plan for direct

patient

care.

Recollection of Goldilocks and the Three Bears is pertinent. Pedagogic Community Medicine is too cold, pure patient care too hot: but the integrated product is just right. PATIENT CARE It is generally true of medical care systems that it is the patient’s responsibility to seek out and go to the source of help: emergency rooms, outpatient departments, free-standing clinics and doctor’s private offices. We are now beginning to recognize a concommitant fact: medical care systems exclude individuals and groups of people who either cannot or will not participate in the established means of receiving health services. Departments of Community Medicine are particularly well qualified to identify and meet the needs of medically unreached people, through (1) assessment of health problems within the community; (2) development of theoretic technics for solving these probJune 1976

The American Journal of Medicine

Volume 60

937

IS THERE A DISCIPLINE

OF COMMUNITY

MEDICINE?-BRICKNER

lems; and (3) the conduct of programs which carry out these technics and which bring these groups into contact with health services. In the

development

care programs health depends medicine [28]. education,

of community-based

health

we have learned to recognize that on many factors outside traditional “Planning for health must include-

occupation,

clothing,

housing,

social

or-

ganization-” [29]. It is, of course, unrealistic to expect any health care system to solve the widespread problems of society. It is quite proper, however, that health workers should develop technics and programs to influence these factors. Community Medicine are qualified

Departments of to combine with

workers in other fields for these purposes. An excellent example of the imaginative and the practical in this regard is the Mount Sinai (New York) Department of Community Medicine Urban Extension Program. This project integrates neighborhood conservation, job training and community development with health preservation. Emphasis is placed on the control of lead and carbon monoxide poisoning, home accidents, rat and insect infestations and inadequate heat in winter [30]. The Department of Community Medicine is the extension of the medical institution into the surrounding community; but its roots must be in the hospital. A close relationship to the inpatient services is essential for proper care of people who are sought out and found to be seriously ill. It is high-level fatuity to attempt diagnosis and treatment without prompt and easy access

to a full range of medical

services.

TEACHING The

teaching

of Community

Medicine

should

per-

meate both the undergraduate years and house officer training. In the past it was the unusual young physician who was able to break through the traditional in-hospital orientation [31]; and to recognize in a more than superficial way that the illness of the individual patient was often a consequence of health problems in the community at large [32-341. Major medical centers, with a few notable exceptions [35-381, have until recently lagged in their Community Medicine teaching efforts. The status of Community Medicine has been low, and time in the curriculum jealously guarded. Students rather than faculty have been the most likely source of energy for change [4,5,17]. Some of our institutions have learned only after painful confrontation [39,49] that “the professional school can serve as the two-way intellectual conduit between the problem as it exists in society and what goes on in the university” [ 411. We know that doctors are unlikely to be drawn to this field+unless exposed to it during training by acadamicians and physicians who are imbued with enthu-

936

June 1976

The American Journal of Medlclne

Volume 60

siasm about Community

Medicine. The role-model

is

all important [ 42). Medical students learning to deliver-care to a population need to be with someone who is not merely talking about but actually delivering comprehensive health careand who is sufficiently competent and confident in this role to merit their respect and admiration. The failure to observe this important aspect of the learning process has undoubtedly contributed to the chronic, unsuccessful attempts to teach preventive medicine and public health

[181. Teaching

goals

in Community

Medicine

include

the development of appropriate student and house staff attitudes; the provision of information and skills; and opportunity for practical demonstration and participation in planning and implementing health service programs [ 18,43,44]. The teaching of Community Medicine will never be time well spent in a crowded academic schedule, if it is purely didactic. “There is . . . no stimulus like the hint of a coming practical application” [45]. Education in the profession of medicine is never an end in itself, always a means to an end [ 46.471. RESEARCH Research means to seek again, to subject the status quo to fresh analysis. Since Community Medicine is in a state of ferment and rapid growth, research in this field is particularly likely to yield new and unanticipated developments. The methods of classic research in Medicine, the laboratory-hospital model, are not adequate to deal with the health problems of populations [48] and of isolated groups within the community. Community Medicine is uniquely equipped to conduct, instead, social health research. This work is concerned with the interrelationship between the environment and health: between social problems and disease; and with “balancing the equation of resources and demand” [49]. Fruitful research in Community Medicine during the recent past and the present includes both theoretic and practical work. Important examples are: Development and program of the team approach to health care [50]; study of health needs within families, and program development [53]; methods for analysis and attempts at control of disorders widespread in the community (hypertension, atherosclerosis, diabetes, malignancy, tuberculosis, mental illness and retardation) [ 16.54-601. INTEGRATION The integration of patient care, teaching and research is characteristic of the best in Community Medicine as it is practiced in the United States today. Two examples are cited.

IS THERE A. DISCIPLINE

OF COMMUNITY

The Beth Israel (Boston) Ambulatory Care Program (BIAC) [61] established in 1973, is a successor to

tient through the Emergency which may be painful, upsetting

the traditional

patient

general

clinic.

This unit was created

following an analysis of concept which showed that the standard

and performance outpatient depart-

ment was outmoded. The BIAC program recognizes that the cost of outpatient department treatment for the majority of patients sicians

is paid for by insurance: in the inner

city are

that primary inadequate

care phyin number;

and that hospitals must assign higher priority than in the past to ambulatory care needs. The BIAC staff consists of teams of full-time physicians in Medicine, Pediatrics, Obstetrics and Gynecology, and Psychiatry; nurses: social workers; and mid-wives. House officers, including primary care residents, utilize this unit as a major teaching service in ambulatory and family care. BIAC doctors act as personal physicians, with a night call schedule, and responsibility

for their patients

It is noteworthy

if hospitalized.

that in the second

fiscal

year

of

the program the unit ran a deficit of $41,749, a remarkably small loss figure for a major inner-city hospital outpatient department. A Rape Follow-Up Team, the first of its kind in the country, was created by the Department of Family and Community Medicine at the University of New Mexico School of Medicine (Albuquerque) [62]. This unit offers rape victims crisis care in the Emergency Room, and broad-based follow-up treatment in the Family Practice Center. The creators of this program recognize that the health needs of the rape patient are complex, often requiring more comprehensive care than can be provided by a gynecologist or psychiatrist alone. The team consists of physicians, physician’s assistants and medical students. When a rape victim comes to the Emergency Room one of the team is called; counseling is provided; and the need for coordination with the police and other physicians is made clear to both the patient and the Emergency Room staff. The team

member

acts as an advocate

for the pa-

is strongly

MEDICINES-BRICKNER

Room experience, and mystifying. The

urged to return

for follow-up

care.

To date, 84 per cent have done so compared to 8 per cent before the program was started. Through team work of this nature, the ability of patients and professional staff to handle effectively the rape trauma syndrome [63], to achieve proper control of the threat of pregnancy and venereal disease, and to work with the police in securing evidence is enhanced. Long-term harmful effects of the assault are treated. A major result of the team’s research has been passage by the New Mexico Legislature of one of the first model state rape laws in the country [64]. CONCLUSION Community pline.

Medicine

Through

is a distinct

Community

and definable

Medicine

disci-

Departments

medical schools and hospitals, patient and research programs are conducted

ed fashion, concerned with a broad definition health which is beyond the range of other clinical partments. Because

Community

Medicine

of

care, teaching in an integratof de-

is a developing

field, and Departments of Community Medicine are not rigidly tied to traditional approaches, there exist unusual opportunities for new design and fresh insight. Community Medicine is in the fore of Medicine’s ability to evolve with the society around us. Community Medicine both identifies the need for change, and acts as an agent for the change. There are obstacles. The most difficult challenges we face are obtaining curriculum time for a new discipline which, to those caught in “the vice-like irrational grip of tradition” [ 181, may not appear worthy; and ridding ourselves of the stereotype that the hospital can be the single unified for all community people. These problems the inherent value body of theory clear.

source

of health

care

are being resolved, however, and of community medicine as a new

and practice

becomes

increasingly

REFERENCES

1. Editorial, JAMA 224: 522, 1973. 2. 3.

4. 5. 6.

Shaw GB: The Doctor’s Dilemma, New York, Brentano’s, 1911, p 19. Deuschle KW: An historical perspective, Chap 20, Community Medicine (Lathem W, Newberry A, eds). New York, Appleton-Century-Crofts, 1970, p 337. Kaplan NM: Community Medicine As An Academic Discipline. Arch Intern Med 129: 124, 1972. Sweeting JG: The Medical Center and the community. P and S Quart 15: 22, 1970. Jenner E: An Inquiry Into the Causes and Effects of the Variolae Vaccinae, a Disease Discovered in Some of the Western Counties of England, Particularly Gloucest-

7. 8. 9. 10. 11. 12.

June 1976

ershire, and Known by the Name of the Cow Pox. London, S. Low, 1798. (Reprinted in Camac CNB: EpochMaking Contributions to Medicine, Surgery and the Allied Sciences, New York, W. B. Saunders, 1909.) Gentleman’s Magazine (London). 69: 380, 1799. Castiglioni A: A History of Medicine, New York, Knopf, 1941, p 926. Old Testament. Leviticus, Chap 13, Verses 45. 46. Rosen G: Historical evolution of primary prevention. Bull NY Acad Med 51: 9, 1975. Flexner A: Medical Education in the United States and Canada. New York, Carnegie Foundation, 19 10, p 67. Bryant JH: Community medicine: a look at the future. Chap

The American Journal of Medicine

Volume 60

939

IS THERE A DISCIPLINE OF COMMUNITY MEDICINE?-ERICKNER

13. 14.

15.

16. 17. 16.

19. 20.

21.

22. 23. 24. 25. 26. 27.

28

29. 30.

31.

32.

33.

34.

35.

36. 37.

940

19, Community Medicine (Lathem W. Newbery A, eds), New York, Appleton-Century-Crofts, 1970, p 311. Warren MD: The concept of community medicine. Community Health (Bristol) 4: 275, 1973. Brickner PW, Greenbaum D, Kaufman A, O’Donnell F, O’Brien JT, Scalice R, Scandizzo J, Sullivan T: A clinic for male derelicts. Ann Intern Med 77: 565, 1972. Brickner PW, Duque T, Kaufman A, Sarg M, Jahre JA, Maturlo S, Janeski JF: The homebound aged-a medically unreached group. Ann Intern Med 82: 1, 1975. Kark SL: From medicine in the community to community medicine. JAMA 226: 1585, 1974. Vuori H: Teaching of community medicine in the United States. Milbank Mem Fund Q 51: 253, 1973. Wray JD: Undergraduate and graduate education in community medicine. Chap 12, Community Medicine (Lathem W, Newbery A, eds), New York, Appleton-CenturyCrofts, 1970. Brotherston J: The specialty of community medicine. R Sot Health J 93: 203, 1973. Smith DE: Runaways and their health problems in HaightAshbury during the summer of 1967. Am J Pub Health 59: 2046, 1969. Minkowski WL, Weiss RC, Heidbreder GA: The County of Los Angeles Health Department Youth Clinics. Am J Pub Health 61: 757, 1971. Stoeckle JD, Anderson WH, Page J, Brenner J: The free medical clinics. JAMA 219: 603, 1972. Gibson CD: The neighborhood health center: the primary unit of health care. Am J Pub Health 58: 1188, 1968. Geiger JH: The neighborhood health center. Arch Environ Health 14: 912, 1967. Gillespie GM: Project Head Start and Dental Care-one summer of experience. Am J Pub Health 58: 90, 1968. Hoekelman RA: A 1969 Head Start medical program. JAMA 219: 730, 1972. Velazquez G: Community medicine as an experiment in health care. Chap 10, Community Medicine (Lathem W, Newbery A, eds), New York, Appleton-Century-Crofts, 1970. The Graduate Education of Physicians. The Report of the Citizen’s Commission on Graduate Medical Education. Chicago, American Medical Association, 1966, p 86. Davies AM: What are comprehensive health services? (Discussion). lsraeii J Med Sci 10: 55, 1974. Richter ED, Jackson S, Peeples S, Wood C, Volante R: Housing and health-a new approach. Am J Pub Health 10: 878, 1973. Lewis EC: A longitudinal study of potential change agents in medicine: a preliminary report. J Med Educ 44: 1029, 1969. de la Burde B, Shapiro IM: Dental lead, blood lead, and pica in urban children. Arch Environ Health 30: 281, 1975. Greenley JR, Gillespie DP, Lindenthal JJ: A Race riot’s effect on psychological symptoms. Arch Gen Psychiatry 32: 1189, 1975. Ayres SM, Evans R, Licht D, Griesbach J, Reimold F, Ferrand EF, Criscitiello A: Health effects of exposure to high concentrations of automotive emissions. Arch Environ Health 27: 168, 1973. Egeberg RO: Balance between medical education and medical service in medical school. JAMA 204: 792, 1968. Gibson CD: Will the urban university medical center join the community? J Med Educ 45: 144, 1970. Goodrich CH, Olendzki M, Deuschle KW: Mount Sinai’s appreach to the East Harlem community. Bull NY Acad

June 1976

The American Journal of Medicine

Volume 60

38.

39. 40. 41.

42. 43. 44.

45. 46.

47. 48. 49.

50. 51. 52.

53. 54.

55. 56. 57.

58. 59. 60.

61. 62.

63. 64.

Med 46: 97, 1970. Deuschle KW: A University’s Response to Demands for Care: Community Medicine at Kentucky. J Med Educ 44: 755, 1969. Bergen SS, Schatzki M: New directions for an urban hospital. JAMA 215: 935, 1971. Leevy CM, Phillips E, Bergen SS: The community and medical education. Ann Intern Med 82: 832, 1975. McDermott W: The university as an agent of change. Chap 2, Community Medicine (Lathem W, Newbery A, eds), New York, Appleton-Century-Crofts, 1970. Cope 0: Man, mind and medicine. The Doctor’s Education. Philadelphia, J. B. Lippincott, 1968, p 105. Brickner, PW: The outlook for ambulatory services. Hosp Prog 56: 64, 1975. Welsh KS, Deuschle KW: Developing a community laboratory for medical teaching programs. J Med Educ 43: 969, 1968. Flexner A: Medical education in the United States and Canada. New York, Carnegie Foundation, 1910, p 59. McDermott W: Community medicine as an experiment in health care (discussion). Chap 10, Community Medicine (Lathem W, Newbery A, eds), New York, Appleton-Century-crofts, 1970, p 133. Burnum JF: Primary care within the academic tradition. JAMA 233: 974, 1975. Sheps CG: Integration of hospitals and community medicine. Israeli J Med Sci 10: 5, 1974. Brotherston JHF: Community medicine as an experiment in health care (discussion). Chap 10, Community Medicine (Lathem W. Newbery A. eds), New York, Appleton-Century-crofts, 1970, p 131. Wise H, Beckhard R, Rubin I, Kyte AL: Making health teams work. Cambridge (Mass), Ballinger, 1974. Wilson FA, Neuhauser D: Health services in the United States. Cambridge (Mass), Ballinger, 1974, p 187. Kark SL, Mainemer N, Abramson JH, Levav I, Kurtzman C: Community Medicine and Primary Health Care. Int J Epidemiol 2: 419, 1973. Silver GA: Family medical care: a design for health maintenance. Cambridge (Mass), Ballinger, 1974. Reichman LB, Cooper BM, Blumenthal S, Block G, O’Hare 0, Chaves AD, Alderman MH, Deming QB, Farber SJ, Thomson GE: Hypertension testing among high school students. J Chron Dis 28: 161, 1975. Morris JN: Primary prevention of heart attack. Bull NY Acad Med 51: 62, 1975. Selikoff IJ: Recent perspectives in occupational cancer. Ambio 4: 14, 1975. Lilis R, Anderson H, Nicholson WJ, et al.: Prevalence of disease among vinyl chloride and polyvinyl chloride workers, Ann NY Acad Sci 246: 22, 1975. Eisenberg L: Primary prevention and early detection in mental illness. Bull NY Acad Med 51: 118, 1975. Dexter LA: Screening and prevention of high-grade mental retardation. Bull NY Acad Med 51: 169, 1975. Hochstrasser DL, Nickerson GS, Deuschle KW: Sociomedical approaches to community health problems. Milbank Memorial Fund Quart 44: 345, 1966. Berarducci AA, DelBanco TL, Rabkin MT: The teaching hospital and primary care. N Engl J Med 292: 615. 1975. Kaufman A, Hilaski S. Di Vasto P, Vander Meer J, Eppler B: Total health needs of the rape victim. J Fam Prac 2: 225, 1975. Burqess AW, Holmstrom LL: Rape trauma syndrome. Am J Psychiatry 131: 981, 1974. New Mexico Statute Compilation 1953, Section 40A-9-20 through 40A-9-26, approved April 3, 1975.