Quaternary prevention: first, do not harm / Prevenção quaternária: primeiro não causar dano / Prevención cuaternaria: primero no hacer daño

Clinical prevention, under the influence of public health, has been organised in a chronological manner since the middle of the 20th century. A paradigm shift from a chronological to a constructivist relationship-based preventive pattern of care1 offers new insights into the practice of doctors. This paradigm shift brings to light the concept of quaternary prevention, a critical look at medical activities with an emphasis on the need not to harm. Quaternary prevention addresses the fundamental question of what constitutes too much or too little medicine. It is the fourth form of disease prevention, but also the fourth frame of action for family doctors (Figure 1). The shift from time-based prevention towards a relationship-based organisation offers new perspectives into physicians' work. The physicians observe themselves and question the ethical limits of their activities. In this sense, quaternary prevention is aimed more at the doctor than the patient. Moreover, the four definitions of prevention, published in the Wonca Dictionary of Family Medicine,2 offer a structured way to discuss the activities of family doctors, including ethical considerations on the patient-doctor encounter. Quaternary prevention, also known as P4, is a new term for an old concept: first, do not harm. This concept enforces disciplines and attitudes such as evidence-based medicine, quality assurance, defensive medicine, avoiding abusive nosographic diagnoses and ethical issues including those linked to overinformation, and overmedicalisation.3

Prevenção quaternária: as bases para sua operacionalização na relação médico-paciente / Quaternary prevention: the basis for its operationalization in the doctor-patient relationship / Prevención cuaternaria: las bases para su operacionalización en la relación médico-paciente

O objetivo deste artigo é apresentar as bases clínicas e conceituais para se operacionalizar a prevenção quaternária na prática dos serviços de Atenção Primária à Saúde e no ambiente de ensino e/ou programa de residência em medicina de família. Utilizou-se o modelo aprimorado de Calgary-Cambridge como substrato organizativo da consulta médica, de modo a inserir a prevenção quaternária em dois momentos: diagnóstico e plano de cuidados. Para fortalecer a prevenção quaternária nesses dois momentos da consulta discute-se: a) os eixos conceituais das doenças (anatomopatológico, fisiopatológico, semiológico e epidemiológico); b) as abordagens explicativas do fenômeno do adoecimento (ontológica e dinâmica); e c) o sofrimento em relação ao tempo (presente e futuro), diferenciando o sofrimento vivenciado no presente das preocupações com a saúde futura. Conclui-se que apesar das limitações da proposta, a formalização da prevenção quaternária no processo de consulta pode auxiliar a reduzir o automatismo diagnóstico e prescritivo que muito tem medicalizado as expressões do adoecer no cotidiano dos serviços da atenção primária à saúde.

The aim of this paper is to present the clinical and conceptual basis to operationalize quaternary prevention in primary healthcare services and teaching contexts and/or residency programmes in family medicine. The enhanced Calgary-Cambridge model of medical consultation is used as an organizational matrix to insert quaternary prevention in two moments: diagnosis and care plan. To strengthen quaternary prevention in these two consultation moments, the discussion explores: a) conceptual disease axes (pathological, physiopathological, semiological and epidemiological); b) illness explanatory approaches (ontological and dynamic); and c) suffering in relation to time (present and future), differentiating present lived suffering from concerns about future health. We conclude that despite limitations of the proposed framework, formalising quaternary prevention in the consultation process can help reduce the diagnostic and prescribing automatism, which has medicalized many illness expressions in the routines of primary health care services.

El objetivo de este artículo es presentar las bases clínicas y conceptuales para operacionalizar la prevención cuaternaria en la práctica de los servicios de Atención Primaria de Salud y contextos de educación y/o programas de residencia en medicina familiar. Se utilizó el modelo mejorado de Calgary-Cambridge como sustrato organizativo de la consulta médica para insertar la prevención cuaternaria en dos etapas: diagnóstico y plan de atención a la salud. Para reforzar la prevención cuaternaria en estos dos momentos de la consulta la discusión explora: a) los ejes conceptuales de las enfermedades (anatomopatológico, fisiopatológico, semiológico y epidemiológico); b) los enfoques explicativos de las enfermedades (ontológico y dinámico); y c) el sufrimiento con respecto al tiempo (presente y futuro), para diferenciar el sufrimiento vivido en el presente de las preocupaciones con la salud futura. Se concluye que a pesar de las limitaciones de la propuesta, la formalización de la prevención cuaternaria en el proceso de la consulta puede ayudar a reducir el automatismo diagnóstico y prescriptivo que mucho tiene medicalizado las expresiones del padecimiento en el cotidiano de los servicios de atención primaria de salud.