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Conflicts Between Public Health and Medical Care

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There is an apparent lack of understanding of the very weak correlation between the important indices of public health and medical care. This is hardly surprising since the former is focussed on improving the health status in populations while medical care measures are based on outcomes in individuals.

Efforts to improve the health of the general population are typically addressed to diseases and behaviors that increase the risk of identifiable preventable disease and disability. We discourage smoking to reduce the risk of a variety of cancers, heart and lung diseases. We set speed limits for cars, require seat belts, and helmets for bike riders to reduce the severity of traumatic injuries. We mandate vaccination for children to prevent epidemics of infectious diseases. We institute quarantine to minimize the risk of the spreading of communicable diseases.

In sharp contrast, medical care is a service delivered to a patient. The object of care is to modify, reduce or eliminate the signs and symptoms of disease. The classification of diseases as acute or chronic reflects the potential relative success of treatment. An oft quote shibboleth that you can't make an asymptomatic man feel better is an oblique statement reflecting the goal of much medical care.

The substitution of the term health care for medical care has led, in no small part, to the confusion between public health and medical care. This has resulted in the introduction of measures and programs that have failed to adequately examine the likely costs of both the intended and unintended consequences.

We are now beginning to see the tip of the iceberg. Consider the revolutionary change in the fundamental structure of medical practice where increasing numbers of physicians are no longer individual practitioners or independent contractors but rather employees of hospitals and other health organizations. It appears this has increased the cost structure for many medical services. Even more staggering change is a result of an aging population that requires more services together with the introduction of services with higher costs. Taken together, these could swamp any savings achieved by attempts to reduce misuse, abuse or fraud or increase efficiency in the medical care delivery system.

We have adopted changes to the health care system assuming they will result in an improvement of the health of the population or the quality of medical care delivered to our citizens. There has been, in most cases, no mandate requiring controlled pilot studies to show better outcomes and/or at decreased costs before their adoption. Almost every day another study is published that highlights this flaw. Today it was the results of a study of the prospective demands of the care required by patients with dementia. With the demographic trends working against us, the costs for the care of these patients is projected to be more than cancer and heart disease.

Although it is not a simple task, we should take this example seriously and carefully study what is likely in our future. From where I sit, at best, there is a very cloudy horizon. The road ahead is scattered with an abundance of some potentially large sinkholes. We would be well advised to attempt to determine their size and depth before we find ourselves on the bottom of a deep pit that is difficult to avoid and where escape is, at best, frightfully expensive.

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