Making a difference: now it's your turn

It has to be public health. To significantly improve health care
means preventing or minimising the risk of ill health in the first place.
Derek Wanless thinks so, the evidence would suggest so and a significant
number of 'rapid responders' say so. Evidence shows that the benefits of
exercise, weight control, a healthy diet, responsible alcohol consumption
and not smoking have a beneficial affect on just about every organ system
in the body, by maintaining and even improving physiological organ
function and reducing the risks of pathological changes. It is quite
simple really!

Competing interests:
None declared

Evidence for efficacy of specific treatment for many chronic medical,
non-life-threatening conditions is provided by randomized trials. However,
it is largely ignored that only a subset of patients respond well to such
'evidence-based' therapy, and some patients may even be harmed by it.

Therefore treatment of these chronic diseases should be guided by evidence
obtained from the very patient that is consulting you in your office, not
from a group result obtained elsewhere in patients that may differ from
your patient. A method to achieve this is to treat your patients according
to rigourous scientific rules: comparison with placebo, randomisation,
double blinding, outcome measures that are both relevant to the patient's
life and scientifically sound. These so called n of 1 trials, as proposed
by Guyatt and Sackett(1), should be a standard facility in hospitals and
GP's offices. They are applicable not only to frequent conditions for
which many trials have been performed, but also to rare diseases for which
little therapeutic evidence exists.

(1) NEJM 1986; 314:889

Competing interests:
None declared

Continuity of care is valued highly by both patients and doctors [1].
Switching family doctors is uncommon in the UK [2].Continuity of care is
much more than good communication skills, it is the place where patient
and doctor develop trust, a sense of ongoing responsibility, built on
shared experiences and longevity of care [1, 3]. It is the recognition
that illness is more extensive than disease, and the role of the doctor,
is the relief of suffering [4] It is associated with improved compliance,
fewer mistakes, and better health outcomes [1]. Amidst the current health
reforms in England, it is vital that the opportunity for, and benefits, of
continuity of care are preserved.

References:

1. Marshall, M. and T. Wilson, Competition in general practice. BMJ,
2005. 331(7526): p. 1196-1199.

2. Edwards, N., Using markets to reform health care. BMJ, 2005.
331(7530): p. 1464-1466.

3. Mainous, A.G., III, M.A. Goodwin, and K.C. Stange, Patient-
Physician Shared Experiences and Value Patients Place on Continuity of
Care. Ann Fam Med, 2004. 2(5): p. 452-454.

4. Heath, I. and K. Sweeney, Medical generalists: connecting the map
and the territory. BMJ, 2005. 331(7530): p. 1462-1464.

Competing interests:
None declared

Diabetes education is key to the effective control and prevention of
complications. As any other medical strategy aimed at preventing diseases
or complications, diabetes education costs money and the ROI will only be
visible after a few years. There are three major external obstacles to the
success of diabetes education: physicians, health plan administrators and
government health officials. Most physicians suffer from a syndrome called
"Pedestal Effect" that make them feel like the kings of the universe and
for whom to deal with an educated patient is a threat to their divinity
because the well informed patient "tries to interfere" in medical
decisions. Most health plan administrators, mainly in developing
countries, are unable to think preventive medicine as a means to reduce
costs of complications because they are only driven by immediate profits.
Government health officials usually suffer from two major
deficiencies: profound ignorance in terms of investing in prevention and
the regrettable position of many government heath care institutions that
do not consider health investments as a top priority. Although the target
of all the needed educational strategies the patient is nothing else that
a victim of ignorance of decision makers.

Augusto Pimazoni, MD

Medical Consultant for Health Education Projects,
Sao Paulo, Brazil

Competing interests:
Medical Marketing Consultant for the Health Care Industry