14PART 1 The Profession of Medicine

crisis of confidence many patients feel toward HCPs and the health care

system. Studies demonstrate that an unambiguous, strong recommendation by trusted HCPs is most often the reason that patients, including those who are vaccine hesitant, choose to vaccinate. Strategies

for counseling vaccine-hesitant and vaccine-resistant patients will be

presented and examples of strong vaccine recommendations provided.

Presenting strategies to increase vaccine demand at a system and policy

level is beyond the scope of this chapter. While some physicians may

have roles that allow them to act at this level, all physicians can act and

influence their individual patients. Strategies to create active vaccine

demand at the individual level alone will not solve vaccine hesitancy,

but vaccine hesitancy cannot be addressed without these efforts. For

further discussion of immunization principles and vaccine use, see

Chap. 123.

■ VACCINE COVERAGE AND OUTBREAKS

The epidemiologic data from measles outbreaks over the past 10 years

provide an interesting illustration of the effects of vaccine opposition

and hesitancy. For further discussion of measles, see Chap. 205.

North America Herd immunity occurs when enough individuals

in a population become immune to an infectious disease, usually

through vaccination, that transmission of the infection stops. The level

of immunity (or level of vaccine coverage) required to confer herd

immunity varies with the specific infectious disease. Because measles is

a highly contagious virus, a coverage rate of 93–95% must be achieved

for vaccination to confer herd immunity and interrupt measles transmission. National coverage estimates place one-dose measles vaccine

coverage rates in 2-year-old children at 92% in the United States and

88% in Canada. In spite of these relatively high levels of coverage in

young children, numerous measles outbreaks have occurred in both

countries since 2010 (Table 3-1).

The vast majority (>80%) of measles cases described in Table 3-1

occurred in under- or completely unvaccinated individuals. Of note,

many of these outbreaks highlight pockets of significantly under- or

unvaccinated individuals that are not apparent in national vaccine coverage statistics. Moreover, many of the outbreaks listed in Table 3-1 were

ignited by unvaccinated returned travelers from areas with existing

TABLE 3-1 Measles Outbreaks in North America

YEAR/PLACE NO. OF CASES REASON

2010/Canada 70 An infected traveler to the 2010 Winter Olympics transmitted infection to an under- and unvaccinated local population

in British Columbia.

2011/Canada 776 Disease was imported from France by an unvaccinated returned traveler to Quebec. The outbreak spread in a

nonvaccinating religious community and outside that community. A majority of cases occurred in under- and

unvaccinated persons.

2011/United States 118 Of 118 cases, 46 were in returned travelers from Europe and Asia/Pacific regions; 105 cases (89%) occurred in

unvaccinated persons.

2013/United States 58 Disease was imported by a returned unvaccinated traveler from Europe. The outbreak spread in a nonvaccinating

religious community in New York.

2014/Canada 433 Disease was imported from the Netherlands. The outbreak spread in a nonvaccinating religious community in British

Columbia.

2014/United States 383 The outbreak occurred in nonvaccinating religious communities in Ohio.

2015/United States 147 A multistate/multicountry outbreak was linked to Disneyland amusement park. More than 80% of cases occurred in

unvaccinated persons.

2015/Canada 159 Disease was imported from the United States (part of the Disneyland outbreak) by an unvaccinated traveler. The

outbreak spread in a nonvaccinating religious community in Quebec.

2017/United States 75 The outbreak occurred in an under-vaccinated community in Minnesota; 95% of patients were unvaccinated.

2018/United States 375 Disease was imported by returned unvaccinated travelers from Israel. The outbreak spread in nonvaccinating religious

communities in New York and New Jersey.

2019/Canada 31 Disease was imported from Vietnam by a returned traveler to British Columbia. The outbreak spread throughout

local area schools in under- and unvaccinated persons and resulted in a province-wide measles mass immunization

campaign for schoolchildren.

2019/United States 1282 Outbreaks occurred in 10 states; 73% of cases (~935) were linked to outbreaks in nonvaccinating religious communities

in New York.

Source: Centers for Disease Control and Prevention and Public Health Agency of Canada.

since Edward Jenner introduced the first vaccine against smallpox in

the eighteenth century. So why did the World Health Organization

rank these attitudes as one of the ten greatest threats to public health in

2019? Are current opposition and hesitancy any different from what has

been seen before? Many sociologists, public health experts, and health

care providers (HCPs) argue yes. Recent social and cultural trends,

combined with new communication formats, have converged to create

a particularly potent form of hesitancy and what some have labeled a

crisis of confidence. This crisis manifests as a lack of trust in specific

vaccines, vaccine programs, researchers, HCPs, the health care system,

pharmaceutical companies, academics, policymakers, governments,

and authority in general. (See “Focus: COVID-19 Vaccine Hesitancy,”

below.)

The roots of modern vaccine hesitancy and opposition—defined as

delay or rejection of vaccines in spite of availability—vary depending

on the place and the population. For some individuals and communities, pseudoscience and false claims about the safety of existing vaccines

(e.g., an unsupported link between measles vaccine and autism) have

driven fears, increased hesitancy, and decreased acceptance. For others,

real safety events, such as the association of narcolepsy with a specific

pandemic influenza vaccine (Pandemrix), have justified concerns. In a

few locations (e.g., Ukraine, Pakistan), vaccine hesitancy is the result

of failed health systems or even state failures. Finally, for some groups,

including some fundamentalist religious groups and alternativeculture communities, vaccine hesitancy and opposition reflect exclusion from and rejection of mainstream society and allopathic health

care and manifest as a deep distrust of these institutions and their

HCPs. Although the genesis of modern vaccine hesitancy is multifactorial, its outcomes are uniform: a decrease in vaccine demand and

uptake, a decrease in coverage by childhood and adult vaccines, and

an increase in vaccine-preventable diseases, outbreaks, and epidemics

of disease. Addressing this crisis and moving people from vaccine

hesitancy and refusal to acceptance and active demand require intervention at multiple levels: the individual, the health system (including

public health), and the state.

This chapter will define vaccine hesitancy and briefly describe its

determinants and effects in North America (the United States and

Canada). Physicians and other HCPs are well positioned to address the

Vaccine Opposition and Hesitancy

15CHAPTER 3

outbreaks or epidemics, who spread disease into an unvaccinated or

under-vaccinated community. Many of the outbreaks were contained

within the nonvaccinating community, but several spread to other

under-vaccinated communities geographically contiguous with the

outbreak community. More concerning still are the cases and outbreaks

originating in communities that had not previously been identified as

nonvaccinating. These cases likely highlight pockets of unvaccinated

individuals who object for cultural rather than religious reasons. In the

past, these nonvaccinating individuals did not exist in large enough

clusters to sustain the spread of measles. Of further concern is the

number of individuals included in outbreak statistics who have had one

or sometimes even two doses of vaccine and who were thought to be

protected but who still end up with the disease. The assumption is that

one or two doses provide full disease immunity, but this is not always

true. Often, individual level characteristics (age, immune compromise,

etc.) affect the individual’s response to the vaccine and their level of

protection. In other instances, vaccine protection can wane over time,

thus leaving fully immunized individuals susceptible to infection. In

fact, when herd immunity breaks (i.e., the level of immunity in a community becomes too low to prevent transmission of disease), the occurrence of cases even in fully immunized persons is seen, as reflected in

outbreak statistics. As a result of decreased vaccination rates and the

resulting disruption of herd immunity, these individuals may become

more identifiable as non-immune.

Outside North America Although overall coverage rates may still

be high in North America, they are lower in other parts of the world. In

Samoa, for example, measles–mumps–rubella (MMR) vaccine coverage

before a recent outbreak was 31%; in the Philippines, it was 67%. Twenty

years ago, vaccine coverage was sufficiently high in some parts of the

world, including Europe, that an unvaccinated traveler from a nonvaccinating community to most regions would have been protected by herd

immunity at their destinations. Today that is not the case: such travelers

are likely to become infected in a country with active measles transmission and return home to spread the infection into their communities

and possibly beyond. Thus active measles transmission, whether at

home or abroad, places individuals who rely on herd immunity (e.g.,

immunocompromised persons and young infants) at increased risk.

■ FACTORS IN VACCINE HESITANCY

Vaccination coverage rates provide an estimate of the proportion of

children or adults in the population who have been vaccinated, but

they do not indicate the proportion of individuals who are vaccine

hesitant. An individual may be fully vaccinated but still be hesitant

about the safety and effectiveness of vaccines, or an individual may

be unvaccinated as a result of access issues but may not be hesitant.

Therefore, in attempts to understand a patient’s lack of vaccination, it is

important to distinguish persons who are hesitant and refuse vaccines

from those who need assistance to access the health care system and

successfully complete vaccination. To this end, an understanding of

vaccine hesitancy and its determinants is needed.

Vaccine hesitancy and opposition are defined by the World Health

Organization’s SAGE Working Group on Vaccine Hesitancy as a “delay

in acceptance or refusal of vaccines despite availability of vaccination

services.” The SAGE group describes vaccine hesitancy as “complex

and context specific, varying across time, place, and vaccines.”

It is useful to frame vaccine acceptance as a continuum pyramid,

with active demand for all vaccines representing the largest group at

the bottom of the pyramid and outright refusal of all vaccines depicted

in the smallest group at the top. In the middle lies vaccine hesitancy,

in which the degree of vaccine demand and acceptance varies. Fortunately, for disease control efforts, most individuals fall within the

active-demand category or, if they are hesitant, still accept all vaccines.

Hesitancy can be influenced by complacency, convenience, and confidence (Fig. 3-1).

Complacency is self-satisfaction when accompanied by a lack of

awareness for real dangers or deficiencies. Complacency exists in

communities and individuals when the perceived risks of vaccinepreventable diseases are low and vaccination is not deemed a necessary

preventive action. This attitude can apply to vaccination in general or

to specific vaccines, such as influenza vaccines. Actual or perceived

vaccine efficacy and effectiveness contribute to complacency. Patients

who are complacent about vaccine-preventable diseases prioritize

other lifestyle or health factors over vaccination. These individuals can

be influenced toward vaccination by a strong recommendation from

a trusted HCP or a local influenza outbreak. They can be influenced

away from vaccination by a vaccine scare or misinformation on social

• Strong distrust of health system/pharmaceutical industry/government

• Strong-willed and committed against vaccines

• Negative or traumatic experiences with HCPs and health system

• May use natural approach to health/alternative HCPs

• May have strong religious/moral considerations for refusal

• May cluster in communities (geographic and online)

• Vaccination is very unlikely; alternative strategies to protect individual and community must be discussed.

Refuses

• Questions safety and necessity of vaccines

• Actively seeks information from many sources

• Has conflicting feelings on whom to trust

• Social norm is not vaccinating.

• May have had negative or traumatic experience with health system

• Vaccination may not occur; a strong trust relationship with HCP and many visits and conversations are

 required.

Late and

selective

• Focused on vaccine risks

• Conversation with trusted HCP strongly influential

• Trusts HCPs

• Actively seeking information and wants to verify it

• Wants advice specific for their child

• Confused by conflicting information

• Social norm is vaccinating, but individual may feel conflicted by this norm.

• Vaccination requires longer conversation and may require multiple visits.

• Focused toward vaccine risk

• Complacency: low perceived benefits of vaccination

• Can move up or down continuum as a result of various influences (HCP

 recommendation, vaccine scare, outbreak)

• Trusts HCPs and health system

• Convenience: need few barriers to vaccination

• Vaccination requires longer conversation but likely can be performed at same

 visit; potential exists to move to active demand.

Hesitant – minor doubts

and concerns

• Confidence

• Considers vaccines important

• Considers vaccines safe

• Trusts HCP/vaccines/health system

• Social norm is vaccinating

• Very short conversation with HCP about vaccination, in which HCP

 should address any questions to maintain active-demand status

Active demand – no doubts or

concerns

Accepts

vaccines

Rejects

vaccines

Characteristics

Presumptive

Communication

Approach

Hesitant – many

doubts and

concerns

Participatory

Communication

Approach

FIGURE 3-1 Vaccine acceptance continuum. HCPs, health care providers. (Adapted from J Leask et al: BMC Pediatrics 12:154, 2012; AL Benin et al: Pediatrics 117:1532, 2006;

and E Dubé, NE MacDonald: The Vaccine Book, 2016, pp. 507-528.)

16PART 1 The Profession of Medicine

media. Finally, the real or perceived ability of patients to take the action

required for vaccination (i.e., self-efficacy) influences the role complacency plays in hesitancy and willingness to seek vaccination.

Convenience is determined by the degree to which conversations

about vaccination and other services can be provided in culturally

safe contexts that are convenient and comfortable for the individual.

Clearly, convenience varies by community, health clinic, and even

patient. Persons who are criticized or scolded for not vaccinating

themselves or their children may not feel comfortable or safe accessing

health services. Factors such as affordability, geographic accessibility,

language, and health literacy are important considerations when evaluating the convenience of existing clinical care. Any of these factors

can affect vaccine acceptance and can push a patient who has some

hesitancy toward vaccinating or not vaccinating.

Confidence is based on trust in the safety and efficacy of vaccines,

in the health care system that delivers vaccines (including HCPs), and

in the policymakers or governments who decide which vaccines are

needed and used. A continual erosion of confidence around vaccination, health systems, and governments drives today’s hesitancy and

has been amplified by larger social and cultural trends in medicine,

parenting, and information availability.

■ SOCIAL AND CULTURAL TRENDS

Individualized Health Care Over the past 30 years, the focus of

medicine and health care has shifted to patient-oriented, individualized care, with an increasing emphasis on treatment and prevention

options tailored to the individual patient. In vaccination programs,

this shift has manifested as requests for individualized vaccine recommendations and customized immunization schedules. The increasing

personalization of medicine, while positive overall, has forced public

health away from a focus on the community and its common good and

has created tension between individual rights and community health.

Parenting Trends The desire for an individualized approach to

medicine and vaccination reflects broader cultural trends concerning

individual risk management: accordingly, the individual is to blame

for bad outcomes, and public institutions cannot be trusted to manage

technological (i.e., vaccine-related) risks. This viewpoint is directly

linked with cultural shifts in parenting and social norms defining

what it means to be a “good parent.” The image of a good parent has

been reframed to refer to someone whom several investigators have

described as “a critical consumer of health services and products,

accounting for their own individual situation as they see it with little

regard for the implications of their decision on other children.” The

archetypical good parent no longer unquestioningly trusts HCPs and

other authorities and experts. According to this social norm, “good

parents” should seek individual medical advice that is tailored for their

child and specific to that child’s needs. While in essence not a bad

thing, this norm can conflict directly with public health vaccine recommendations and schedules that are organized to maximize community health and to facilitate efficient provision of care at a community

level.

Traditional Media Newspapers, radio, and television have been

criticized for their coverage of vaccines and in particular their coverage

of the alleged link between MMR vaccine and autism. By offering equal

coverage throughout the early to mid-2000s for both the scientific

evidence and unproven claims of MMR vaccine harms, traditional

media outlets provided a forum and a megaphone for the spread of

pseudoscience. Equal coverage leads to false equivalencies. Celebrity

advocates further amplified the message via this channel. The boost

that traditional media provided to active vaccine resistance and, less

directly, to vaccine hesitancy has not been adequately measured but

must be considered in any discussion of vaccine hesitancy. After

headlines about multiple outbreaks of measles and other vaccinepreventable diseases and continued direct criticism of the equalcoverage approach, some traditional media now reject and attempt to

discredit pseudoscience. The effect this stance will have on increasing

vaccine confidence is unknown.

The Internet and Social Media Approximately 90% of Americans

and 91% of Canadians use the Internet, and 80% of Americans and

60% of Canadians have a social network profile. Widespread access

to social media can be empowering, but it is also problematic. The

Internet and social media require users to select their information

sources, creating an environment described as an “echo chamber” in

which individuals choose information sources harboring beliefs or

opinions similar to their own and thereby reinforcing their existing

views. This situation has created a new platform for further spread of

vaccine misinformation (inaccuracies due to error) and disinformation

(deliberate lies) and has provided a forum for vaccine-resistant individuals, including celebrities, to organize and raise funds to support their

efforts. The harmful effects of Internet and social media use on vaccine

hesitancy have been well documented. Vaccine hesitancy increases for

parents who seek their information from the Internet. Unfortunately,

public health and health care institutions have been slow to adapt to

this new communication medium and to recognize its influence and

impact. In this medium, personal stories and anecdotes are now viewed

as data and disproportionately influence vaccine decision-making,

while traditional, more authoritative, fact-based information sources

are deemphasized. Centralized monitoring by jurisdiction of vaccine

misinformation and disinformation, with summaries of the relevant

discourses and rebuttals provided to HCPs, has been proposed as a

potential way to counter the influence of social media on vaccine hesitancy. While such strategies have been applied in single jurisdictions

and appear to have had some success, their applicability to a broader

context is unknown. Moreover, the resources for such a coordinated

response have not been made available, and individual HCPs have been

left to counter popular, shifting, viral communications on their own,

patient by patient.

As with traditional media, the social media landscape appears to

be shifting. In 2019, the proliferation of anti-vaccination information

combined with measles outbreaks in North America and increasing

pressure from health leaders led large social media companies (Facebook, Instagram, Pinterest) to deemphasize anti-vaccination information by removing relevant advertisements and recommendations and

decreasing their prominence in search results. While it is too soon to

determine the effects of these measures, critics are skeptical that they

will have the intended result of reducing vaccine misinformation and

disinformation. Early evidence shows that misleading content is still

widely available, with anti-vaccine advertisements now using the term

“vaccine choice” to avoid censorship. More disturbingly, public health

advertisements in support of vaccination have been included in social

bans and removed from social media sites.

In a more grassroots effort, providers and vaccine supporters have

united on social media to provide online support and evidence-based

facts to providers and others who support vaccines when they are

attacked digitally by anti-vaccine supporters. For example, Shots Heard

Round the World (www.shotsheard.com) is an effort led by two U.S.

pediatricians to provide advice and support for HCPs who speak out

about the importance of vaccines. Such efforts harness the power of

social media in ways similar to those used by vaccine opponents and

may prove successful in combating vaccine hesitancy.

Given these social and cultural trends, no one should be surprised

when individuals now question vaccination, express confusion about

conflicting information and information sources, and feel unsure

whom to trust. Their broader social context is telling them they should

question everything and trust no one. This message is reinforced via

misinformation and disinformation on social media. Recent vaccinepreventable disease outbreaks illustrate that effective engagement

with individuals cannot be accomplished through one-way, top-down

information provision (which still is often the de facto choice for health

system communication), but rather requires a dialogue that takes into

account the social processes surrounding individual vaccination decisions. It is at the interface between the individual and the health system

in which conversations between HCPs and their patients can have the

greatest impact. It is critical for all HCPs to discuss vaccines and provide strong vaccine recommendations—including HCPs who do not

administer vaccines but who have established trust with their patients.

 

12PART 1 The Profession of Medicine

TABLE 2-2 Recommendations from Physical Activity Guidelines for Americans

AGE RECOMMENDATIONS

3–5 years • Preschool-aged children (ages 3 through 5 years) should be physically active throughout the day to enhance growth and development.

• Adult caregivers of preschool-aged children should encourage active play that includes a variety of activity types.

6–17 years • It is important to provide young people opportunities and encouragement to participate in physical activities that are appropriate for their age,

that are enjoyable, and that offer variety.

• Children and adolescents ages 6 through 17 years should do 60 min (1 h) or more of moderate-to-vigorous physical activity daily:

• Aerobic: Most of the 60 min or more per day should be either moderate- or vigorous-intensity aerobic physical activity and should include

vigorous-intensity physical activity on at least 3 days a week.

• Muscle-strengthening: As part of their 60 min or more of daily physical activity, children and adolescents should include musclestrengthening physical activity on at least 3 days a week.

• Bone-strengthening: As part of their 60 min or more of daily physical activity, children and adolescents should include bone-strengthening

physical activity on at least 3 days a week.

18–64 years • Adults should move more and sit less throughout the day. Some physical activity is better than none. Adults who sit less and do any amount of

moderate-to-vigorous physical activity gain some health benefits.

• For substantial health benefits, adults should do at least 150 min (2 h and 30 min) to 300 min (5 hours) a week of moderate-intensity or 75 min

(1 h and 15 min) to 150 min (2 h and 30 min) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderateand vigorous-intensity aerobic activity. Preferably, aerobic activity should be spread throughout the week.

• Additional health benefits are gained by engaging in physical activity beyond the equivalent of 300 min (5 h) of moderate-intensity physical

activity a week.

• Adults should also do muscle-strengthening activities of moderate or greater intensity and that involve all major muscle groups on 2 or more

days a week, as these activities provide additional health benefits.

≥65 years • The key guidelines for adults also apply to older adults. In addition, the following key guidelines are just for older adults:

• As part of their weekly physical activity, older adults should do multicomponent physical activity that includes balance training as well as

aerobic and muscle-strengthening activities.

• Older adults should determine their level of effort for physical activity relative to their level of fitness.

• Older adults with chronic conditions should understand whether and how their conditions affect their ability to do regular physical activity

safely.

• When older adults cannot do 150 min of moderate-intensity aerobic activity a week because of chronic conditions, they should be as

physically active as their abilities and conditions allow.

Moderate-intensity physical activity: Aerobic activity that increases a person’s heart rate and breathing to some extent. On a scale relative to a person’s capacity,

moderate-intensity activity is usually a 5 or 6 on a 0 to 10 scale. Brisk walking, dancing, swimming, or bicycling on a level terrain are examples. Vigorous-intensity physical

activity: Aerobic activity that greatly increases a person’s heart rate and breathing. On a scale relative to a person’s capacity, vigorous-intensity activity is usually a 7 or 8

on a 0 to 10 scale. Jogging, singles tennis, swimming continuous laps, or bicycling uphill are examples. Muscle-strengthening activity: Physical activity, including exercise

that increases skeletal muscle strength, power, endurance, and mass. It includes strength training, resistance training, and muscular strength and endurance exercises.

Bone-strengthening activity: Physical activity that produces an impact or tension force on bones, which promotes bone growth and strength. Running, jumping rope, and

lifting weights are examples.

Source: Adapted from U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. Washington, DC: U.S. Department of Health

and Human Services; 2018. Available at https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf.

Patients with persistent complaints of poor sleep quality or excessive

daytime somnolence or with witnessed apneic spells may benefit from

screening for sleep disorders, prior to consideration of a formal sleep

study. A number of clinical tools have been developed to screen for

sleep apnea, including the Epworth Sleepiness Scale, the STOP (snoring,

tiredness, observed apnea, high blood pressure) Questionnaire, and the

STOP-Bang Questionnaire (STOP plus assessment of BMI, age, neck

circumference, and gender), among others. The U.S. Preventive Services

Task Force found that current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults

owing to a lack of validation data in primary care settings. Nonetheless,

the high prevalence and significant health consequences of sleep apnea

suggest that clinicians should be alert for its potential presence, particularly in patients who are obese with symptoms of excessive daytime

somnolence or witnessed apnea episodes. Other sleep disorders, such as

restless leg syndrome, may be identified with simple history.

Weight Management Overweight and obesity are prevalent in

epidemic proportions in the United States and other industrialized

nations (Chaps. 401 and 402). Since 1985, the prevalence of obesity

in the United States has increased from ~10 to ~35%, and the prevalence of overweight is now ~40%. Overweight and obesity disproportionately affect individuals in lower socioeconomic strata and in

many underserved minority populations, including black Americans,

Latino Americans, and American Indians. In all race/ethnic groups,

both overweight and obesity are associated with adverse health consequences, including diabetes, certain cancers, cardiovascular diseases,

and degenerative joint disease. Eating disorders such as anorexia and

bulimia are much less common but pose major health consequences

for affected patients and should be suspected particularly in younger

women with history of rapid weight shifts or underweight status.

Weight loss is one of the most difficult preventive interventions to

achieve and sustain over time. However, several key factors can assist

the patient and clinician, and early referral to a dietician can be very

helpful. The first therapeutic goal is to aim for weight stabilization.

Many of the risks of overweight and obesity are driven more strongly

by continued weight gain, rather than overweight/obese status per se.

Working with the patient to find initial strategies for weight maintenance can be a successful initial step with success for many patients.

For those who can progress to considering weight loss, it is critical

to help the patient understand that there is no standard solution.

Experimentation and documentation are key. Tools to assist patients

can include food and weight logs, activity logs, and smart phone apps.

Some patients respond best to structured approaches such as intermittent fasting regimens or commercial dietary programs where meals are

provided. Any of these approaches can be tried with or without social

group supports.

The key construct for weight loss is, of course, negative calorie balance. This is achieved through a combination of reduced caloric intake

and increased physical activity. Patients may already understand, from

prior weight loss attempts, what combination works best for them to

achieve this. Some patients find that they cannot lose weight without

increasing their exercise. For many, reduction of caloric intake is most

efficient. Encouraging the patient to find what works for them is most

important. The same principle holds for dietary content. Well-done

feeding studies indicate that weight loss is dependent far more on the

reduction of caloric intake than on the relative composition of fat, protein, and carbohydrate in the diet. There may be other medical reasons

Vaccine Opposition and Hesitancy

13CHAPTER 3

to choose one approach over another, but if not, encouraging the

patient to pick one approach and document the results is an important

start. Once weight loss is achieved, increase in activity is often required

for its successful maintenance.

Tobacco Cessation (see Chap. 454) Escaping nicotine dependence is another major, but critical, challenge to prevention and

wellness efforts. The addictive effects of nicotine have been well

documented, with effects that can last for years after successful cessation. Assessing a patient’s past history of cessation attempts and

current readiness for change are key first steps in forging a successful

approach. Frequent follow-up and reinforcement, as well as use of

nicotine replacement therapy and other cessation-promoting medications, are additional critical elements. Recidivism is the rule, and

patients should expect to resume smoking and attempt again as they

journey to tobacco cessation. Electronic cigarettes have some evidence

for benefit in adult smoking cessation, but their potential for use by

adolescents and young adults who are not smokers represents a major

public health threat for a new generation of nicotine addiction, with

unknown health consequences as a result of the high doses of nicotine delivered to developing organs, including the brain. Vaping of

other substances, often in association with flavoring compounds, has

also been associated with pulmonary and cardiovascular damage and

should be actively discouraged.

■ VACCINATION (CHAP. 123)

One of the major advances in public health that has contributed to

increases in health and longevity worldwide is the development of safe

and effective vaccinations against endemic and epidemic infectious

diseases. Patients should be counseled regarding age-appropriate vaccinations for their children and for themselves. Some individuals may

be reluctant to receive a vaccination; in these cases, listening to the

patient’s concerns is important, followed by explanation of the benefits

to the individual, their family, and their community and review of the

low risk for potential harms. It is true to say that no current vaccines

are ever worse than the disease they prevent, although side effects may

occur rarely. Thorough knowledge of the data on side effect rates and

of efficacy will aid the clinician in helping the patient make a fully

informed decision.

■ MENTAL HEALTH AND ADDICTION

Assessment for depression and cognitive impairment is important

to address when patients exhibit symptoms or they or their family

members express concerns. Both of these common conditions play a

major role in reducing quality of life and are high on patients’ lists of

concerns, even if not clearly expressed. Screening tools for depression

are reviewed in Chap. 452. Cognitive function decline with aging or

comorbid illness, including depression, should be anticipated. Assessment tools such as the General Practitioner Assessment of Cognition

or the Mini-CogTM test are widely available and effective rapid assessment tools.

Alcohol and Opioids (see Chaps. 453 and 456) Alcohol

dependence and abuse are common and underdiagnosed. Rapid

screening tools have proven efficacy for identifying patients with alcohol problems. In a systematic review, the CAGE (cut down, annoyed,

guilty, eye opener) questionnaire was most effective at identifying

alcohol abuse and dependence, with reasonable sensitivity and high

specificity. The present opioid epidemic in the United States presents

a new and substantial public health challenge given the high potential

for dependency and abuse of these drugs. Rapid screening tools are

available to assist clinicians in screening for opioid dependence.

■ ACCIDENTS AND SUICIDE

Regular assessment of patient safety through simple questions about

seat belt use, domestic violence, and gun safety in the home continues

to be an important part of health promotion and wellness. Longstanding recommendations for assessment of suicidal ideation among

patients with depression or a history of suicide attempts also continue

to be relevant.

APPROACH TO THE PATIENT

In the context of a clinical visit focused on health assessment, health

promotion, and prevention, the basic skills of history-taking are

of paramount importance. Much of the evaluation, counseling,

and management that focus on health promotion and prevention

also require engagement and buy-in from the patient in order to

assist with recognition of contributing behaviors and to promote

adherence to therapeutic plans. Therefore, in addition to standard

history-taking, additional skills such as motivational interviewing

and eliciting patient commitments and contracting may prove of

significant value. The availability of additional tools to assist with

screening, monitoring, and chronic management, both online and

through wearable devices and mobile health technologies, is rapidly expanding, with uncertain implications for the future. Major

research gaps exist in our understanding of how best to employ these

newer technologies to improve health outcomes. Concepts of behavioral economics are being explored to better understand the psychology of decision-making and incentives as a means to improve

lifestyle choices and adherence to treatment plans (Chap. 481).

The limited time available to clinicians and patients during a

wellness visit or periodic health examination (not driven by specific patient issues) makes it important to prioritize assessment and

counseling for factors that affect longevity, health span, and quality

of life over approaches that may have low yield, such as the annual

comprehensive physical examination in an asymptomatic patient.

Setting clear expectations for the content of a wellness visit may be

a first step, and scheduling follow-up visits for findings or to continue indicated counseling are important steps to achieving better

health outcomes.

■ FURTHER READING

Boulware LE et al: Systematic review: The value of the periodic health

evaluation. Ann Intern Med 146:289, 2007.

Dietary Guidelines for Americans, 2020–2025. Washington, DC:

U.S. Department of Agriculture and U.S. Department of Health and

Human Services; 2020. Available at https://www.dietaryguidelines.gov/sites/

default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf.

Irish LA et al: The role of sleep hygiene in promoting public health: A

review of empirical evidence. Sleep Med Rev 22:23, 2015.

Krogsboll LT et al: General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and

meta-analysis. BMJ 345:e7191, 2012.

U.S. Department of Health and Human Services: Physical Activity

Guidelines for Americans, 2nd ed. Washington, DC: U.S. Department of

Health and Human Services; 2018. Available at https://health.gov/sites/

default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf.

U.S. Preventive Services Task Force webpage. Available at https://

www.uspreventiveservicestaskforce.org/uspstf/.

Vaccines have been recognized as one of the top public health achievements of the twentieth century. Dramatic declines in the morbidity and

mortality of vaccine-preventable diseases have been observed, and the

contribution of vaccines to the elimination, control, and prevention of

infectious disease cannot be overstated. However, opposition and hesitancy to vaccines exist and are not new. Vaccine hesitancy has existed

3 Vaccine Opposition and

Hesitancy

Julie A. Bettinger, Hana Mitchell

 

10PART 1 The Profession of Medicine

TABLE 2-1 Guidelines and Key Recommendations from the Dietary Guidelines for Americans, 2020–2025

GUIDELINES KEY RECOMMENDATIONS

1. Follow a healthy dietary pattern at every life

stage. For the first 6 months of life, infants should

exclusively be fed human milk, or iron-fortified

formula if human milk is unavailable. From 6 to

12 months, infants should be introduced to a

variety of complementary nutrient-dense foods.

From 12 months to older adulthood, the dietary

pattern should meet nutrient needs, help achieve

a healthy body weight, and reduce the risk of

chronic disease.

2. Customize and enjoy nutrient-dense food and

beverage choices to reflect personal preferences,

cultural traditions, and budgetary considerations.

The Dietary Guidelines provide a framework of

several dietary patterns intended to be customized

to individual needs and preferences, as well as

the foodways of the diverse cultures in the United

States.

3. Focus on meeting food group needs with nutrientdense foods and beverages, and stay within

calorie limits. Nutrient-dense foods provide

vitamins, minerals, and other health-promoting

components and have no or little added sugars,

saturated fat, and sodium. A healthy dietary

pattern consists of nutrient-dense forms of

foods and beverages across all food groups, in

recommended amounts, and within calorie limits.

4. Limit foods and beverages higher in added sugars,

saturated fat, and sodium, and limit alcoholic

beverages. At every life stage, meeting food group

recommendations, even with nutrient-dense

choices, fulfills most of a person’s daily calorie

needs and sodium limits, with little room for extra

added sugars, saturated fat, or sodium, or for

alcoholic beverages.

The Dietary Guidelines’ Key Recommendations for healthy eating patterns should be applied in their

entirety, given the interconnected relationship that each dietary component can have with others. They are

also intended as a framework to accommodate personal preferences, cultural traditions, and budgetary

considerations.

Focus on meeting food group needs with nutrient-dense foods and beverages, and stay within calorie limits to

achieve a healthy weight and reduce the risk of chronic disease.

The core elements that make up a healthy dietary pattern include:

• Vegetables of all types—dark green; red and orange; beans, peas, and lentils; starchy; and other vegetables

• Fruits, especially whole fruit

• Grains, at least half of which are whole grain

• Dairy, including fat-free or low-fat milk, yogurt, and cheese, and/or lactose-free versions and fortified soy

beverages and yogurt as alternatives

• Protein foods, including lean meats, poultry, and eggs; seafood; beans, peas, and lentils; and nuts, seeds, and

soy products

• Oils, including vegetable oils and oils in food, such as seafood and nuts

A healthy eating pattern limits:

• Added sugars—Less than 10% of calories per day starting at age 2. Avoid foods and beverages with added

sugars for those younger than age 2.

• Saturated fat—Less than 10% of calories per day starting at age 2.

• Sodium—Less than 2300 mg per day—and even less for children younger than age 14.

• Alcoholic beverages—Adults of legal drinking age can choose not to drink or to drink in moderation by

limiting intake to 2 drinks or less in a day for men and 1 drink or less in a day for women, when alcohol is

consumed. Drinking less is better for health than drinking more. There are some adults who should not drink

alcohol, such as women who are pregnant.

Meet the U.S. Department of Health and Human Services’ Physical Activity Guidelines for Americans

In tandem with the recommendations above, Americans of all ages—children, adolescents, adults, and older

adults—should meet the Physical Activity Guidelines for Americans to help promote health and reduce the

risk of chronic disease. Americans should aim to achieve and maintain a healthy body weight. The relationship

between diet and physical activity contributes to calorie balance and managing body weight.

Source: Adapted from the Dietary Guidelines for Americans, 2020-2025. Washington, DC: U.S. Department of Agriculture and U.S. Department of Health and Human Services;

2020. Available at https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf.

may be better spent on assessing and counseling the patient on other

aspects of their health, as discussed below. Evidence-based components

that should be included in periodic evaluations focused on health and

prevention include a number of age-appropriate screening tests for

chronic disease and risk factors, preventive interventions including

immunizations and chemoprevention for at-risk individuals, and preventive counseling. The U.S. Preventive Services Task Force publishes

its Guide to Clinical Preventive Services, which contains evidence-based

recommendations from the Task Force on preventive services for

which there is a high degree of certainty that the service provides at

least moderate net clinical benefit (i.e., benefits outweigh harms significantly and to a reasonable magnitude).

Healthy Behaviors and Lifestyles Owing to the paucity of

evidence, the heterogeneity of study designs, and the diverse nature

of interventions studied, many clinicians are uncertain as to how to

deliver advice regarding healthy behaviors and lifestyles. Nevertheless,

adverse behaviors and lifestyles contribute to >75% of premature,

preventable deaths and disability. Estimates from the U.S. National

Health and Nutrition Examination Survey indicate that fewer than 1%

of Americans achieve an optimal heart-healthy eating pattern. Thus,

whereas there are many demands on time during a typical patientclinician encounter, few things may have more impact on longevity,

health, and quality of life for asymptomatic patients than an efficient

approach to assessing, documenting, and improving patients’ health

behaviors. Indeed, the mere act of assessing health behaviors has

been shown to affect patients’ health behaviors. Facility with tools for

assessment of lifestyle and with strategies for counseling are therefore

of paramount importance.

Healthy Eating Patterns (see Chap. 332) Despite the existence

of numerous “fad” diets and seemingly inconsistent recommendations

on dietary composition, there is remarkable agreement about what

should constitute a healthy eating pattern for the broad population to

avoid nutritional deficits (i.e., vitamin deficiency) and excesses (i.e.,

excessive caloric intake) and to maximize potential health (Table 2-1).

Optimal eating patterns consist of whole fruits and vegetables, whole

grains, lean proteins, and healthy oils, and allow for nonfat or low-fat

dairy intake. They tend to exclude frequent ingestion of foods high in

refined sugars and starches, saturated fat, and sodium. Since sodium

and refined sugars and starches are the hallmark of much of the

processed/packaged food supply, a simple rule of thumb is to provide

or cook the majority of one’s own meals starting from whole foods and

emphasizing fruits and vegetables. Likewise, foods prepared outside of

the home tend to have higher fat and sodium content, so special attention to menu choices focused on fruits, vegetables, lean proteins, and

whole grains, while minimizing sauces and dressings, can help most

individuals follow healthier eating patterns when eating food prepared

outside the home. In all cases, sugar-sweetened beverages and nonnutritious snack foods should be minimized. If snacks are included, small

amounts of healthy nuts and seeds or more fruits and vegetables should

be encouraged.

Specific conditions and diseases, such as diabetes, other metabolic

disorders, allergies, and gastrointestinal disorders, may require tailored

approaches to diet. In counseling most patients, the general approach

should focus on whole foods, eating patterns, and appropriate calorie

balance, rather than on specific micronutrients such as electrolytes or

selected vitamins. It should be remembered that most patients have

difficulty understanding nutritional labels on packaged foods, with the

attendant demands on numeracy and health literacy.

Dietary guidelines are published by the U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services every 5 years, and these guidelines have undergone substantial

Promoting Good Health

11CHAPTER 2

evolution over time. The current U.S. Dietary Guidelines and Key

Recommendations for 2020–2025 are summarized in Table 2-1 and

emphasize the importance of healthy eating patterns for every stage of

life, to avoid chronic diseases including obesity, diabetes, cancer, and

cardiovascular disease. The core elements include eating patterns with

nutrient-dense (rather than calorie-dense) whole foods and appropriate caloric intake to achieve and maintain healthy weight. The USDA

guidelines focus on the concept of a healthy plate (rather than the prior

food pyramid) for ease of counseling and adoption. Fifty percent of

the plate should consist of vegetables and whole fruits, with remaining

portions for whole grains and lean protein foods. When using fat for

cooking, it should be done by sauteing in healthier oils (e.g., canola oil),

and addition of judicious amounts of healthy raw oils (e.g., olive oil,

nuts) to dishes is appropriate. Recommendations also focus on limitation of foods and beverages higher in added sugars, saturated fat, and

sodium, and moderation or avoidance of alcohol intake.

The USDA guidelines focus on specific healthy eating patterns that

adhere to these broad recommendations and are appropriate for ~97%

of the general population. They identify a “Healthy U.S.-Style Dietary

Pattern” that adheres closely to the evidence-based Dietary Approaches

to Stop Hypertension (DASH) eating pattern but is customizable for different cultural or personal preferences. Alternative patterns, which vary

more in emphasis than in content, include a “Healthy MediterraneanStyle Dietary Pattern” and a “Healthy Vegetarian Dietary Pattern.”

AGE- AND SEX-SPECIFIC RECOMMENDATIONS Current dietary framework recommendations are generally similar for all life stages from

ages ≥12 months, but recommended levels of caloric intake (and hence

amounts of foods) differ by age, sex, and physical activity level. For

example, recommended caloric intake ranges from 1000 calories/d for

sedentary 2-year-old children to as high as 3200 calories/d for active

16- to 18-year-old young men. Recommended caloric intakes peak in

late adolescence or early adulthood for men and women and gradually

decrease over ensuing decades.

As with all lifestyle counseling aimed at behavior change, dietary

approaches that partner with the patient and utilize motivational interviewing strategies and shared goals and commitments tend to work

best, as described below (see “Approach to the Patient”).

Physical Activity Similar to the approach to counseling regarding

healthy eating patterns, recommendations on participation in physical

activity emphasize the point that any physical activity is better than

none. A simple rule of thumb for patients is: “If you are doing nothing,

do something; and if you are doing something, do more, every day.”

The evidence base for physical activity indicates that the marginal benefits from physical activity are greatest in advancing from no activity to

low levels of moderate activity. With increasing duration and intensity

of activity, there is a continued curvilinear increase in health benefits,

but the marginal gains for each additional minute of moderate-tovigorous activity slowly diminish. Thus, for adults, the recommended

amount of physical activity is 150 min of moderate-intensity or 75 min

of vigorous-intensity aerobic activity per week, performed in episodes

of at least 5 min, and preferably spread throughout the week, plus

participation in muscle-strengthening activity at least 2 days per week.

Additional health benefits can be realized by engaging in physical

activity beyond this amount.

In counseling patients regarding physical activity, it is important to

note that sedentary time (e.g., seated at work or at home in front of electronic screens) has adverse health consequences independent of the lack

of physical activity during these episodes. Therefore, even modest efforts

like standing at the desk and doing gentle stretching for periods during

the day may be beneficial. It is also important to emphasize that participating in a variety of aerobic activities (biking, swimming, walking,

jogging, rowing, elliptical training, stair-climbing, etc.) can be beneficial

and may help to avoid overuse injuries and boredom with the exercise

regimen. If patients choose to participate in muscle-strengthening activities for health improvement, emphasis should be placed on weights

that allow more repetitions (e.g., 3 sets of 15–20 repetitions that can be

performed comfortably, with a rest period in between) and on avoiding

breath-holding and straining against a closed glottis.

SUDDEN CARDIAC DEATH RISK Patients may express concerns regarding the risk of sudden cardiac death during exercise. Whereas the risk

of sudden death during exercise does increase directly with the amount

of time spent exercising, this association is substantially mitigated by

training effects. Thus, patients embarking on an exercise program

should be encouraged to increase the duration of aerobic exercise gradually as tolerated, aiming for episodes of at least 30 min 5 times a week

as an ideal. Once a comfortable duration is reached, incorporating

interval training periods of more intensive activity interspersed during

the exercise can provide greater fitness gains.

EXTREME ENDURANCE ACTIVITIES As with other forms of exercise,

extreme endurance activities such as triathlons and marathons should

be undertaken only with appropriate and graded training. Such activities tend to take a greater toll on the musculoskeletal system over time

than less extreme activities, and they are also associated with measurable damage to the myocardium and greater risks for other organ

damage. Athletes participating in endurance activities routinely have

elevations in cardiac troponin (a specific circulating marker of myocardial cell damage and death) at the end of the race, although elevations

are lower in those who are well trained. Patients and clinicians should

consider the patient’s overall health, specific limitations, potential for

injury, and ability to train in decision-making regarding participation

in endurance events.

AGE-SPECIFIC RECOMMENDATIONS The U.S. Department of Health

and Human Services’ Physical Activity Guidelines for Americans, second

edition (2018) (Table 2-2), recommend that preschool-aged children

(aged 3–5 years) should be physically active throughout the day in a variety of activity types to enhance growth and development. Children and

adolescents aged 6–17 years should participate in ≥60 min of physical

activity daily, most of which should be moderate- or vigorous-intensity

aerobic activity, including vigorous, muscle-strengthening, and bonestrengthening activities at least 3 days a week each. As noted above,

adults aged 18–64 years are recommended to pursue at least 150 min

of moderate-intensity or 75 min of vigorous-intensity aerobic activity

per week (or equivalent combinations), with at least 2 days of musclestrengthening activities. Adults aged ≥65 years should follow the adult

guidelines or be as active as possible as abilities and conditions allow.

For older adults, special emphasis is also placed on multicomponent

physical activity that includes balance training as well as aerobic and

muscle-strengthening activities.

Sleep Hygiene Sleeping between 7 and 9 h per night appears to be

optimal for health in adults aged ≥18 years. Sleeping <7 h is associated

with adverse outcomes, including obesity, diabetes, elevated blood

pressure, cardiovascular disease, depression, and all-cause mortality,

as well as physiologic disturbances such as impaired immune function,

increased pain sensitivity, and impaired cognitive performance. Conversely, achieving appropriate levels of sleep is associated with more

success in weight loss, better blood pressure control among patients

with hypertension, and improved mental health and performance.

Regular sleep more than 9 h per night is appropriate for children and

adolescents or individuals recovering from sleep deprivation or illness,

but for most individuals, the effects on health are uncertain.

Patients often express concerns about the quantity and quality of

their sleep. With aging, both aspects of sleep tend to decline, even without overt sleep disorders. Documentation of sleep using a sleep log may

assist in understanding different types of insomnia and sleep disorders.

Encouraging daily activity to promote fatigue, avoidance of eating and

drinking alcohol too close to bedtime, and regular daily sleep habits

may help patients achieve better sleep. Regular use of sedative medications should generally be discouraged given the high potential for

dependence, addiction, and altered sleep quality.

DISORDERS OF SLEEP The prevalence of sleep-related breathing

disorders, including obstructive sleep apnea (OSA), is poorly documented. A recent systematic review suggested that that the prevalence

of clinically important OSA in the general adult population may be

between 9% and 38%, with higher rates in men versus women, older

versus younger adults, and those with higher versus lower BMI.

 

FIGURE 2-1 Loss of health with aging. Representation of normative aging with

loss of the full stock of health with which individuals are born (indicating gain of

morbidity), contrasted with a squared curve with greater longevity and fuller stock

of health (less morbidity) until shortly before death. The “squared curve” represents

the likely ideal situation for most patients.

worldwide over the last century (largely as a result of public health

practices), increasing emphasis is placed on prevention for the purpose

of preserving quality of life and extending the health span, not just the

life span. Given that all patients will eventually die, the goal of prevention ultimately becomes compression of morbidity toward the end of

the life span; that is, reduction of the amount of burden and time spent

with disease prior to dying. As shown in Fig. 2-1, normative aging

tends to involve a steady decline in the stock of health, with accelerating decline over time. Successful prevention offers the opportunity

both to extend life and to extend healthy life, thus “squaring the curve”

of health loss during aging.

Prevention strategies have been characterized as tertiary, secondary,

primary, and primordial. Tertiary prevention requires rapid action to

prevent imminent death in the setting of acute illness, such as through

percutaneous coronary intervention in the setting of ST-segment elevation myocardial infarction. Secondary prevention strategies focus on

avoiding the recurrence of disease and death in an individual who is

already affected. For example, tamoxifen is recommended for women

with surgically treated early-stage, estrogen receptor–positive breast

cancer, because it reduces the risk of recurrent breast cancer (including

in the contralateral breast) and death. Primary prevention attempts to

reduce the risk of incident disease among individuals with one or more

risk factors. Treatment of elevated blood pressure in individuals who

have not yet experienced cardiovascular disease represents one example of primary prevention that has proven effective in reducing the

incidence of stroke, heart failure, and coronary heart disease.

Primordial prevention is a more recent concept (first introduced in

1979) that focuses on prevention of the development of risk factors

for disease, not just prevention of disease. Primordial prevention

strategies emphasize upstream determinants of risk for chronic diseases, such as eating patterns, physical activity, and environmental

and social determinants of health. It therefore encompasses medical

treatment strategies for some individuals as well as a strong reliance on

public health and social policy. It is increasingly clear that primordial

prevention represents the ultimate means for reducing the burden

of chronic diseases of aging. Once risk factors develop, it is difficult

to restore risk to the low level of someone who never developed the

risk factor. The time spent with adverse levels of the risk factor often

causes irreversible damage that precludes complete restoration of low

risk. For example, individuals with hypertension who are treated back

to optimal levels (<120/<80 mmHg) do have a lower risk compared

with untreated patients with hypertension, but they still have twice the

risk of cardiovascular events as those who maintained optimal blood

pressure without medications. Patients with elevated blood pressure

that is subsequently treated have greater left ventricular mass index,

worse renal function, and more evidence of atherosclerosis and other

target organ damage as a result of the time spent with elevated blood

pressure; such damage cannot be fully reversed despite efficacious therapy with antihypertensive medications. Conversely, as described below

in greater detail, individuals who maintain optimal levels of all major

Promoting Good Health

9CHAPTER 2

may improve adherence; ignoring them will likely lead to therapeutic

failure. Numerous studies demonstrate that, even in high-functioning

health systems, only ~50% of patients are taking recommended,

evidence-based secondary prevention medications, such as statins, by

1 year after a myocardial infarction.

In patients who are eligible for primary prevention strategies, it is

important to frame the discussion around the overall evidence base

as well as an individual patient’s likelihood of benefit from a given

preventive intervention. A first step is to understand the patient’s

estimated absolute risk for disease in the foreseeable future or during

their remaining life span. However, absolute risk estimation and presentation of those risks are generally insufficient to motivate behavior

change. It is critical to assess the patient’s understanding and tolerance

of the risk, their readiness to implement lifestyle changes or adhere

to drug therapy, and their overall preferences regarding use of drug

therapy to prevent an event (e.g., cancer, myocardial infarction, stroke).

The clinician can help the patient by informing them of the risks for

disease and potential for absolute benefits (and harms) from the available evidence-based choices. This may take more than one conversation, but given that diseases, such as cancer and cardiovascular disease,

are the leading causes of premature death and disability, the time is well

spent.

Partnering with the patient through motivational interviewing

may assist in the process of selecting initial approaches to prevention.

Selecting an area that the patient feels they are ready to change can lead

to better adherence and greater achievement of success in the short and

longer term. If the patient is uncertain what course to choose, prudence

would dictate focusing on control of risk factors that may lead to the

most rapid reduction in risk for acute events. For example, blood pressure is both a chronic risk factor and an acute trigger for cardiovascular

events. Thus, if a patient has both significant elevations in blood pressure and dyslipidemia, it would be appropriate to focus initial efforts

on blood pressure control. Likewise, a focus on smoking cessation can

lead to more rapid reductions in risk for acute events than some other

lifestyle interventions.

■ PREVENTION AND HEALTH PROMOTION ACROSS

THE LIFE COURSE

Periodic Health Evaluations The “routine annual physical” has

in many ways become an expected part of the patient-physician relationship in primary care practice. However, evidence for the efficacy

of the periodic health evaluation in asymptomatic adults unselected

for risk factors or disease is mixed and depends on the outcome.

Systematic reviews and meta-analyses of published trials have consistently observed lack of benefit (and also lack of harm) in terms of

total mortality in association with periodic health evaluations. Data

are more heterogeneous but overall suggest no benefit for cancer- or

cardiovascular-specific mortality, with the potential for either benefit

or harm depending on number of evaluations and patient-level factors.

Well-designed studies on nonfatal clinical events and morbidity have

been sparsely reported, but there appear to be no large effects.

Periodic health evaluations do appear to lead to greater diagnosis of

certain conditions such as hypertension and dyslipidemia, as expected.

Likewise, periodic health examinations also improve the delivery of

recommended preventive services, such as gynecologic examinations

and Papanicolaou smears, fecal occult blood testing, and cholesterol

screening. The benefits and risks associated with screening tests are

discussed in detail in Chap. 6. Risks of routine evaluations include

inappropriate testing or overtesting or false-positive findings that

require follow-up and induce patients to worry. Periodic health examinations appear to be associated with less patient worry. On balance,

given the lack of convincing evidence of harm and the potential for

better delivery of appropriate screening, counseling, and preventive

services, periodic health evaluations appear reasonable for general

populations at average risk for chronic conditions.

It is important to note that routine annual comprehensive physical

examinations of asymptomatic adult patients have very low yield and

may take an inordinate amount of time in a wellness visit. Such time

cardiovascular risk factors into middle age through primordial prevention essentially abolish their lifetime risk of developing cardiovascular

disease while also living substantially longer and having a lower burden

and later onset of other comorbid illnesses (compression of morbidity).

Prevention strategies should be distinguished from disease screening strategies. Screening attempts to detect evidence of disease at its

earliest stages, when treatment is likely to be more efficacious than for

advanced disease (Chap. 6). Screening can be performed in service of

prevention, especially if it aids in identifying preclinical markers, such

as dyslipidemia or hyperglycemia, associated with elevated disease risk.

■ HEALTH PROMOTION

In recent decades, medical practice has increasingly focused on clinical

and public health approaches to promote health, and not just prevent

disease. Prevention of disease is a worthy individual and societal goal

in and of itself, but it does not necessarily guarantee health. Health is

a broader construct encompassing more than just absence of disease.

It includes biologic, physiologic, and psychological domains (among

others) in a continuum, rather than occurring as a dichotomous trait.

Health is therefore somewhat subjective, but attempts have been made

to use more objective criteria to define health in order to raise awareness, prevent disease, and promote healthy longevity.

For example, in 2010, the American Heart Association (AHA)

defined a new construct of “cardiovascular health” based on evidence

of associations with longevity, disease avoidance, healthy longevity, and

quality of life. The definition of cardiovascular health is based on seven

health behaviors and health factors (eating pattern, physical activity,

smoking status, body mass index [BMI], and levels of blood pressure,

blood cholesterol, and blood glucose) and includes a spectrum from

poor to ideal. Individuals with optimal levels of all seven metrics

simultaneously are considered to have ideal cardiovascular health. The

state of cardiovascular health for an individual or a population can be

assessed with simple scoring by counting the number of ideal metrics

(out of seven) or applying 0 points for each poor metric, 1 point for

each intermediate metric, and 2 points for each ideal metric, thus

creating a composite cardiovascular health score ranging from 0 to

14 points. Higher cardiovascular health scores in younger and middle

ages have been associated with greater longevity, lower incidence of

cardiovascular disease, lower incidence of other chronic diseases of

aging (including dementia, cancer, and more), compression of morbidity, greater quality of life, and lower health care costs, achieving both

individual and societal goals for healthy aging and further establishing

the critical importance of primordial prevention and cardiovascular

health promotion.

Focusing on health promotion, rather than just disease prevention,

may also provide greater motivation for patients to pursue lifestyle

changes or adhere to clinician recommendations. Extensive literature

suggests that providing patients solely with information regarding

disease risk, or risk reduction with treatment, is unlikely to motivate

desired behavior change. Empowering patients with strategies to

achieve positive health goals after discussing risks can provide more

effective adherence and better long-term outcomes. In the case of

smoking cessation, enumerating only the risks of smoking can lead

to patient inertia and therapeutic nihilism and has proven to be an

ineffective approach, whereas strategies that incorporate positive

health messaging, support, and feedback, with appropriate use of

evidence-based therapies, have proven far more effective.

■ PRIORITIZING PREVENTION STRATEGIES

In secondary prevention, the patient already has manifest clinical disease and is therefore at high risk for progression. The approach should

be to work with the patient to implement all evidence-based strategies

that will help to prevent recurrence or progression. This will typically

include drug therapy as well as therapeutic lifestyle changes to control

ongoing risk factors that may have caused disease in the first place.

Juggling priorities can be difficult, and barriers to implementation are

many, including costs, time, patient health literacy, and patient and

caregiver capacity to organize the regimen. Addressing these potential barriers with the patient can help to forge a therapeutic bond and

 

The Practice of Medicine

7CHAPTER 1

almost instantaneously at any time and from anywhere in the world.

This medium holds enormous potential for the delivery of current

information, practice guidelines, state-of-the-art conferences, journal

content, textbooks (including this text), and direct communications

with other physicians and specialists, expanding the depth and breadth

of information available to the physician regarding the diagnosis and

care of patients. Medical journals are now accessible online, providing rapid sources of new information. By bringing them into direct

and timely contact with the latest developments in medical care, this

medium also serves to lessen the information gap that has hampered

physicians and health care providers in remote areas.

Patients, too, are turning to the Internet in increasing numbers to

acquire information about their illnesses and therapies and to join

Internet-based support groups. Patients often arrive at a clinic visit

with sophisticated information about their illnesses. In this regard,

physicians are challenged in a positive way to keep abreast of the latest

relevant information while serving as an “editor” as patients navigate

this seemingly endless source of information, the accuracy and validity

of which are not uniform.

A critically important caveat is that virtually anything can be published on the Internet, with easy circumvention of the peer-review

process that is an essential feature of academic publications. Both

physicians and patients who search the Internet for medical information must be aware of this danger. Notwithstanding this limitation,

appropriate use of the Internet is revolutionizing information access

for physicians and patients, and in this regard represents a remarkable

resource that was not available to practitioners a generation ago.

Public Expectations and Accountability The general public’s

level of knowledge and sophistication regarding health issues has

grown rapidly over the past few decades. As a result, expectations of

the health care system in general and of physicians in particular have

risen. Physicians are expected to master rapidly advancing fields (the

science of medicine) while considering their patients’ unique needs (the

art of medicine). Thus, physicians are held accountable not only for

the technical aspects of the care they provide but also for their patients’

satisfaction with the delivery and costs of care.

In many parts of the world, physicians increasingly are expected

to account for the way in which they practice medicine by meeting

certain standards prescribed by federal and local governments. The

hospitalization of patients whose health care costs are reimbursed

by the government and other third parties is subjected to utilization

review. Thus, a physician must defend the cause for and duration of a

patient’s hospitalization if it falls outside certain “average” standards.

Authorization for reimbursement increasingly is based on documentation of the nature and complexity of an illness, as reflected by recorded

elements of the history and physical examination. A growing “payfor-performance” movement seeks to link reimbursement to quality of

care. The goal of this movement is to improve standards of health care

and contain spiraling health care costs. In many parts of the United

States, managed (capitated) care contracts with insurers have replaced

traditional fee-for-service care, placing the onus of managing the cost

of all care directly on the providers and increasing the emphasis on preventive strategies. In addition, physicians are expected to give evidence

of their current competence through mandatory continuing education,

patient record audits, maintenance of certification, and relicensing.

Medical Ethics and New Technologies The rapid pace of technological advances has profound implications for medical applications

that go far beyond the traditional goals of disease prevention, treatment, and cure. Cloning, genetic engineering, gene therapy, human–

computer interfaces, nanotechnology, and use of targeted therapies

have the potential to modify inherited predispositions to disease,

select desired characteristics in embryos, augment “normal” human

performance, replace failing tissues, and substantially prolong life span.

Given their unique training, physicians have a responsibility to help

shape the debate on the appropriate uses of and limits placed on these

new technologies and to consider carefully the ethical issues associated

with the implementation of such interventions. As medicine becomes

more complex, shared decision-making is increasingly important, not

only in areas such as genetic counseling and end-of-life care, but also

in diagnostic and treatment options.

Learning Medicine More than a century has passed since the

publication of the Flexner Report, a seminal study that transformed

medical education and emphasized the scientific foundations of medicine as well as the acquisition of clinical skills. In an era of burgeoning

information and access to medical simulation and informatics, many

schools are implementing new curricula that emphasize lifelong learning and the acquisition of competencies in teamwork, communication

skills, system-based practice, and professionalism. The tools of medicine also change continuously, necessitating formal training in the use

of EMRs, large datasets, ultrasound, robotics, and new imaging techniques. These and other features of the medical school curriculum provide the foundation for many of the themes highlighted in this chapter

and are expected to allow physicians to progress, with experience and

learning over time, from competency to proficiency to mastery.

At a time when the amount of information that must be mastered

to practice medicine continues to expand, increasing pressures both

within and outside of medicine have led to the implementation of

restrictions on the amount of time a physician-in-training can spend

in the hospital and in clinics. Because the benefits associated with continuity of medical care and observation of a patient’s progress over time

were thought to be outstripped by the stresses imposed on trainees by

long hours and by fatigue-related errors, strict limits were set on the

number of patients that trainees could be responsible for at one time,

the number of new patients they could evaluate in a day on call, and the

number of hours they could spend in the hospital. In 1980, residents

in medicine worked in the hospital more than 90 hours per week on

average. In 1989, their hours were restricted to no more than 80 per

week. Resident physicians’ hours further decreased by ~10% between

1996 and 2008, and in 2010, the Accreditation Council for Graduate

Medical Education further restricted (i.e., to 16 hours per shift) consecutive in-hospital duty hours for first-year residents. The impact of these

changes is still being assessed, but the evidence that medical errors have

decreased as a consequence is sparse. An unavoidable by-product of

fewer hours at the bedside is an increase in the number of “handoffs”

of patient responsibility from one physician to another. These transfers

often involve a transition from a physician who knows the patient well,

having evaluated that individual on admission, to a physician who

knows the patient less well. It is imperative that these transitions of

responsibility be handled with care and thoroughness, with all relevant

information exchanged and acknowledged. These issues highlight the

challenge our profession has in establishing a reliable measure of physician effectiveness.

The Physician as Perpetual Student From the time physicians graduate from medical school, it becomes all too apparent that

this milestone is symbolic and that they must embrace the role of a

“perpetual student.” This realization is at the same time exhilarating

and anxiety-provoking. It is exhilarating because physicians can apply

constantly expanding knowledge to the treatment of their patients; it is

anxiety-provoking because physicians realize that they will never know

as much as they want or need to know. Ideally, physicians will translate the latter feeling into energy through which they can continue to

improve and reach their potential. It is the physician’s responsibility to

pursue new knowledge continually by reading, attending conferences

and courses, and consulting colleagues and the Internet. This is often a

difficult task for a busy practitioner; however, a commitment to continued learning is an integral part of being a physician and must be given

the highest priority.

The Physician as Citizen Being a physician is a privilege. The

capacity to apply one’s skills for the benefit of fellow human beings

is a noble calling. The physician–patient relationship is inherently

unbalanced in the distribution of power. In light of their influence,

physicians must always be aware of the potential impact of what they

do and say, and must always strive to strip away individual biases and

preferences to find what is best for their patients. To the extent possible,

physicians should also act within their communities to promote health

8PART 1 The Profession of Medicine

and alleviate suffering. Meeting these goals begins by setting a healthy

example and continues in taking action to deliver needed care even

when personal financial compensation may not be available.

Research, Teaching, and the Practice of Medicine The word

doctor is derived from the Latin docere, “to teach.” As teachers,

physicians should share information and medical knowledge with

colleagues, students of medicine and related professions, and their

patients. The practice of medicine is dependent on the sum total of

medical knowledge, which in turn is based on an unending chain of

scientific discovery, clinical observation, analysis, and interpretation.

Advances in medicine depend on the acquisition of new information

through research, and improved medical care requires the transmission

of that information. As part of their broader societal responsibilities,

physicians should encourage patients to participate in ethical and

properly approved clinical investigations if these studies do not impose

undue hazard, discomfort, or inconvenience. Physicians engaged in

clinical research must be alert to potential conflicts of interest between

their research goals and their obligations to individual patients. The

best interests of the patient must always take priority.

To wrest from nature the secrets which have perplexed philosophers in all

ages, to track to their sources the causes of disease, to correlate the vast

stores of knowledge, that they may be quickly available for the prevention

and cure of disease—these are our ambitions.

—William Osler, 1849–1919

■ FURTHER READING

Cheston CC et al: Social media use in medical education: A systematic

review. Acad Med 88:893, 2013.

Cooke M et al: American medical education 100 years after the Flexner report. N Engl J Med 355:1339, 2006.

Excel JL et al: Vaccine development for emerging infectious diseases.

Nat Med 27:591, 2021

Institute of Medicine: Dying in America: Improving Quality and

Honoring Individual Preferences Near the End of Life. Washington,

DC, National Academies Press, 2015.

Institute of Medicine: Improving Diagnosis in Health Care.

Washington, DC, National Academies of Sciences, Engineering, and

Medicine, 2015.

Levine DM et al: Hospital-level care at home for acutely ill adults: A

qualitative evaluation of a randomized controlled trial. J Gen Intern

Med 36:1965, 2021.

Stern DT, Papadakis M: The developing physician—becoming a professional. N Engl J Med 355:1794, 2006.

Vickrey BG et al: How neurologists think: A cognitive psychology

perspective on missed diagnoses. Ann Neurol 67:425, 2010.

West P et al: Intervention to promote physician well-being, job satisfaction, and professionalism. A randomized clinical trial. JAMA

Intern Med 174:527, 2014.

■ GOALS AND APPROACHES TO PREVENTION

Prevention of acute and chronic diseases before their onset has been

recognized as one of the hallmarks of excellent medical practice for

centuries and is now used as a metric for highly functioning health

care systems. The ultimate goal of preventive strategies is to avoid

premature death. However, as longevity has increased dramatically

2 Promoting Good Health

Donald M. Lloyd-Jones,

Kathleen M. McKibbin

Normative aging

with gradual loss of

stock of health

Squaring th

This medium holds enormous potential for the delivery of current

information, practice guidelines, state-of-the-art conferences, journal

content, textbooks (including this text), and direct communications

with other physicians and specialists, expanding the depth and breadth

of information available to the physician regarding the diagnosis and

care of patients. Medical journals are now accessible online, providing rapid sources of new information. By bringing them into direct

and timely contact with the latest developments in medical care, this

medium also serves to lessen the information gap that has hampered

physicians and health care providers in remote areas.

Patients, too, are turning to the Internet in increasing numbers to

acquire information about their illnesses and therapies and to join

Internet-based support groups. Patients often arrive at a clinic visit

with sophisticated information about their illnesses. In this regard,

physicians are challenged in a positive way to keep abreast of the latest

relevant information while serving as an “editor” as patients navigate

this seemingly endless source of information, the accuracy and validity

of which are not uniform.

A critically important caveat is that virtually anything can be published on the Internet, with easy circumvention of the peer-review

process that is an essential feature of academic publications. Both

physicians and patients who search the Internet for medical information must be aware of this danger. Notwithstanding this limitation,

appropriate use of the Internet is revolutionizing information access

for physicians and patients, and in this regard represents a remarkable

resource that was not available to practitioners a generation ago.

Public Expectations and Accountability The general public’s

level of knowledge and sophistication regarding health issues has

grown rapidly over the past few decades. As a result, expectations of

the health care system in general and of physicians in particular have

risen. Physicians are expected to master rapidly advancing fields (the

science of medicine) while considering their patients’ unique needs (the

art of medicine). Thus, physicians are held accountable not only for

the technical aspects of the care they provide but also for their patients’

satisfaction with the delivery and costs of care.

In many parts of the world, physicians increasingly are expected

to account for the way in which they practice medicine by meeting

certain standards prescribed by federal and local governments. The

hospitalization of patients whose health care costs are reimbursed

by the government and other third parties is subjected to utilization

review. Thus, a physician must defend the cause for and duration of a

patient’s hospitalization if it falls outside certain “average” standards.

Authorization for reimbursement increasingly is based on documentation of the nature and complexity of an illness, as reflected by recorded

elements of the history and physical examination. A growing “payfor-performance” movement seeks to link reimbursement to quality of

care. The goal of this movement is to improve standards of health care

and contain spiraling health care costs. In many parts of the United

States, managed (capitated) care contracts with insurers have replaced

traditional fee-for-service care, placing the onus of managing the cost

of all care directly on the providers and increasing the emphasis on preventive strategies. In addition, physicians are expected to give evidence

of their current competence through mandatory continuing education,

patient record audits, maintenance of certification, and relicensing.

Medical Ethics and New Technologies The rapid pace of technological advances has profound implications for medical applications

that go far beyond the traditional goals of disease prevention, treatment, and cure. Cloning, genetic engineering, gene therapy, human–

computer interfaces, nanotechnology, and use of targeted therapies

have the potential to modify inherited predispositions to disease,

select desired characteristics in embryos, augment “normal” human

performance, replace failing tissues, and substantially prolong life span.

Given their unique training, physicians have a responsibility to help

shape the debate on the appropriate uses of and limits placed on these

new technologies and to consider carefully the ethical issues associated

with the implementation of such interventions. As medicine becomes

more complex, shared decision-making is increasingly important, not

only in areas such as genetic counseling and end-of-life care, but also

in diagnostic and treatment options.

Learning Medicine More than a century has passed since the

publication of the Flexner Report, a seminal study that transformed

medical education and emphasized the scientific foundations of medicine as well as the acquisition of clinical skills. In an era of burgeoning

information and access to medical simulation and informatics, many

schools are implementing new curricula that emphasize lifelong learning and the acquisition of competencies in teamwork, communication

skills, system-based practice, and professionalism. The tools of medicine also change continuously, necessitating formal training in the use

of EMRs, large datasets, ultrasound, robotics, and new imaging techniques. These and other features of the medical school curriculum provide the foundation for many of the themes highlighted in this chapter

and are expected to allow physicians to progress, with experience and

learning over time, from competency to proficiency to mastery.

At a time when the amount of information that must be mastered

to practice medicine continues to expand, increasing pressures both

within and outside of medicine have led to the implementation of

restrictions on the amount of time a physician-in-training can spend

in the hospital and in clinics. Because the benefits associated with continuity of medical care and observation of a patient’s progress over time

were thought to be outstripped by the stresses imposed on trainees by

long hours and by fatigue-related errors, strict limits were set on the

number of patients that trainees could be responsible for at one time,

the number of new patients they could evaluate in a day on call, and the

number of hours they could spend in the hospital. In 1980, residents

in medicine worked in the hospital more than 90 hours per week on

average. In 1989, their hours were restricted to no more than 80 per

week. Resident physicians’ hours further decreased by ~10% between

1996 and 2008, and in 2010, the Accreditation Council for Graduate

Medical Education further restricted (i.e., to 16 hours per shift) consecutive in-hospital duty hours for first-year residents. The impact of these

changes is still being assessed, but the evidence that medical errors have

decreased as a consequence is sparse. An unavoidable by-product of

fewer hours at the bedside is an increase in the number of “handoffs”

of patient responsibility from one physician to another. These transfers

often involve a transition from a physician who knows the patient well,

having evaluated that individual on admission, to a physician who

knows the patient less well. It is imperative that these transitions of

responsibility be handled with care and thoroughness, with all relevant

information exchanged and acknowledged. These issues highlight the

challenge our profession has in establishing a reliable measure of physician effectiveness.

The Physician as Perpetual Student From the time physicians graduate from medical school, it becomes all too apparent that

this milestone is symbolic and that they must embrace the role of a

“perpetual student.” This realization is at the same time exhilarating

and anxiety-provoking. It is exhilarating because physicians can apply

constantly expanding knowledge to the treatment of their patients; it is

anxiety-provoking because physicians realize that they will never know

as much as they want or need to know. Ideally, physicians will translate the latter feeling into energy through which they can continue to

improve and reach their potential. It is the physician’s responsibility to

pursue new knowledge continually by reading, attending conferences

and courses, and consulting colleagues and the Internet. This is often a

difficult task for a busy practitioner; however, a commitment to continued learning is an integral part of being a physician and must be given

the highest priority.

The Physician as Citizen Being a physician is a privilege. The

capacity to apply one’s skills for the benefit of fellow human beings

is a noble calling. The physician–patient relationship is inherently

unbalanced in the distribution of power. In light of their influence,

physicians must always be aware of the potential impact of what they

do and say, and must always strive to strip away individual biases and

preferences to find what is best for their patients. To the extent possible,

physicians should also act within their communities to promote health

8PART 1 The Profession of Medicine

and alleviate suffering. Meeting these goals begins by setting a healthy

example and continues in taking action to deliver needed care even

when personal financial compensation may not be available.

Research, Teaching, and the Practice of Medicine The word

doctor is derived from the Latin docere, “to teach.” As teachers,

physicians should share information and medical knowledge with

colleagues, students of medicine and related professions, and their

patients. The practice of medicine is dependent on the sum total of

medical knowledge, which in turn is based on an unending chain of

scientific discovery, clinical observation, analysis, and interpretation.

Advances in medicine depend on the acquisition of new information

through research, and improved medical care requires the transmission

of that information. As part of their broader societal responsibilities,

physicians should encourage patients to participate in ethical and

properly approved clinical investigations if these studies do not impose

undue hazard, discomfort, or inconvenience. Physicians engaged in

clinical research must be alert to potential conflicts of interest between

their research goals and their obligations to individual patients. The

best interests of the patient must always take priority.

To wrest from nature the secrets which have perplexed philosophers in all

ages, to track to their sources the causes of disease, to correlate the vast

stores of knowledge, that they may be quickly available for the prevention

and cure of disease—these are our ambitions.

—William Osler, 1849–1919

■ FURTHER READING

Cheston CC et al: Social media use in medical education: A systematic

review. Acad Med 88:893, 2013.

Cooke M et al: American medical education 100 years after the Flexner report. N Engl J Med 355:1339, 2006.

Excel JL et al: Vaccine development for emerging infectious diseases.

Nat Med 27:591, 2021

Institute of Medicine: Dying in America: Improving Quality and

Honoring Individual Preferences Near the End of Life. Washington,

DC, National Academies Press, 2015.

Institute of Medicine: Improving Diagnosis in Health Care.

Washington, DC, National Academies of Sciences, Engineering, and

Medicine, 2015.

Levine DM et al: Hospital-level care at home for acutely ill adults: A

qualitative evaluation of a randomized controlled trial. J Gen Intern

Med 36:1965, 2021.

Stern DT, Papadakis M: The developing physician—becoming a professional. N Engl J Med 355:1794, 2006.

Vickrey BG et al: How neurologists think: A cognitive psychology

perspective on missed diagnoses. Ann Neurol 67:425, 2010.

West P et al: Intervention to promote physician well-being, job satisfaction, and professionalism. A randomized clinical trial. JAMA

Intern Med 174:527, 2014.

■ GOALS AND APPROACHES TO PREVENTION

Prevention of acute and chronic diseases before their onset has been

recognized as one of the hallmarks of excellent medical practice for

centuries and is now used as a metric for highly functioning health

care systems. The ultimate goal of preventive strategies is to avoid

premature death. However, as longevity has increased dramatically

2 Promoting Good Health

Donald M. Lloyd-Jones,

Kathleen M. McKibbin

Normative aging

with gradual loss of

stock of health

Squaring the curve

with compression

of morbidity

Stock of health

0

0 20 40

Age

60 80 100

0.2

0.4

0.6

0.8

1

 

The Practice of Medicine

5CHAPTER 1

historical and clinical information, imaging studies, laboratory results,

and medication records. These data can be used to monitor and reduce

unnecessary variations in care and to provide real-time information

about processes of care and clinical outcomes. Ideally, patient records

are easily transferred across the health care system; however, technological limitations and concerns about privacy and cost continue to

limit broad-based use of EMRs in many clinical settings.

For all of the advantages of EMRs, they can create distance between

the physician and patient if care is not taken to preserve face-to-face

contact. EMRs also require training and time for data entry. Many

providers spend significant time entering information to generate

structured data and to meet billing requirements. They may feel pressured to take short cuts, such as “cutting and pasting” parts of earlier

notes into the daily record, thereby increasing the risk of errors. EMRs

also structure information in a manner that disrupts the traditional

narrative flow across time and among providers. These features, which

may be frustrating for some providers, must be weighed against the

advantages of ready access to past medical history, imaging, laboratory

data, and consultant notes. Furthermore, the effort, time, and attention

needed to maintain and utilize the EMR have led to a growing sense of

dissatisfaction among physicians, lessening professional and personal

well-being as a result. Clearly, this is an area of daily practice that

requires improvement both for the delivery of safe and optimal care

and physician wellness.

It is important to emphasize that information technology is merely

a tool and can never replace the clinical decisions that are best made by

the physician. Clinical knowledge and an understanding of a patient’s

needs, supplemented by quantitative tools, still represent the best

approach to decision-making in the practice of medicine.

THE PATIENT–PHYSICIAN RELATIONSHIP

The significance of the intimate personal relationship between physician

and patient cannot be too strongly emphasized, for in an extraordinarily

large number of cases both the diagnosis and treatment are directly dependent on it. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.

—Francis W. Peabody, October 21, 1925,

Lecture at Harvard Medical School

Physicians must never forget that patients are individuals with problems that all too often transcend their physical complaints. They are

not “cases” or “admissions” or “diseases.” Patients do not fail treatments; treatments fail to benefit patients. This point is particularly

important in this era of high technology in clinical medicine. Most

patients are anxious and fearful. Physicians should instill confidence

and offer reassurance, but they must never come across as arrogant,

patronizing, impatient, or hurried. A professional attitude, coupled

with warmth and openness, can do much to alleviate anxiety and to

encourage patients to share all aspects of their medical history. Empathy and compassion are the essential features of a caring physician. The

physician needs to consider the setting in which an illness occurs—in

terms not only of patients themselves but also of their familial, social,

and cultural backgrounds. The ideal patient–physician relationship

is based on thorough knowledge of the patient, mutual trust, and the

ability to communicate.

Informed Consent The fundamental principles of medical ethics

require physicians to act in the patient’s best interest and to respect

the patient’s autonomy. Both principles are reflected in the process of

informed consent. Patients are required to sign consent forms for most

diagnostic or therapeutic procedures. Many patients possess limited

medical knowledge and must rely on their physicians for advice. Communicating in a clear and understandable manner, physicians must

fully discuss the alternatives for care and explain the risks, benefits, and

likely consequences of each alternative. The physician is responsible

for ensuring that the patient thoroughly understands these risks and

benefits; encouraging questions is an important part of this process. It

may be necessary to go over certain issues with the patient more than

once. This is the very definition of informed consent. Complete, clear

explanation and discussion of the proposed procedures and treatment

can greatly mitigate the fear of the unknown that commonly accompanies hospitalization. Often the patient’s understanding is enhanced

by repeatedly discussing the issues in an unthreatening and supportive

way, answering new questions that occur to the patient as they arise.

Continuing efforts to educate the patient are essential. Patients are

frequently inhibited from understanding by the fear of an uncertain

future and potential impact of the illness on themselves and their families. Clear communication can also help alleviate misunderstandings

in situations where complications of intervention occur. Special care

should also be taken to ensure that a physician seeking a patient’s

informed consent has no real or apparent conflict of interest.

Approach to Grave Prognoses and Death No circumstance is

more distressing than the diagnosis of an incurable disease, particularly

when premature death is inevitable. What should the patient and family be told? What measures should be taken to maintain life? What can

be done to optimize quality of life?

Transparency of information, delivered in an appropriate manner,

is essential in the face of a terminal illness. Even patients who seem

unaware of their medical circumstances, or whose family members

have protected them from diagnoses or prognoses, often have keen

insights into their condition. They may also have misunderstandings

that can lead to additional anxiety. The patient must be given an

opportunity to speak with the physician and ask questions. A wise and

insightful physician uses such open communication as the basis for

assessing what the patient wants to know and when he or she wants

to know it. On the basis of the patient’s responses, the physician can

assess the most appropriate time and pace for sharing information.

Ultimately, the patient must understand the expected course of the

disease so that appropriate plans and preparations can be made. The

patient should participate in decision-making with an understanding

of the goal of treatment (palliation) and its likely effects. The patient’s

religious beliefs should be taken into consideration. Some patients may

find it easier to share their feelings about death with their physician,

nurses, or members of the clergy than with family members or friends.

The physician should provide or arrange for emotional, physical,

and spiritual support, and must be compassionate, unhurried, and

open. In many instances, there is much to be gained by the laying on

of hands. Pain should be controlled adequately, human dignity maintained, and isolation from family and close friends avoided. These

aspects of care tend to be overlooked in hospitals, where the intrusion

of life-sustaining equipment can detract from attention to the individual person and encourage concentration instead on the life-threatening

disease, against which the battle ultimately will be lost in any case. In

the face of terminal illness, the goal of medicine must shift from cure to

care in the broadest sense of the term. Primum succurrere, first to help,

is a guiding principle. In offering care to a dying patient, a physician

should be prepared to provide information to family members and deal

with their grief and sometimes their feelings of guilt or even anger.

It is important for the physician to assure the family that everything

reasonable is being done. A substantial challenge in these discussions

is that the physician often does not know exactly how to gauge the

prognosis. In addition, various members of the health care team may

offer different opinions. Good communication among providers is

essential so that consistent information is provided to patients. This is

especially important when the best path forward is uncertain. Advice

from experts in palliative and terminal care should be sought whenever

appropriate to ensure that clinicians are not providing patients with

unrealistic expectations. For a more complete discussion of end-oflife care, see Chap. 12.

Maintaining Humanism and Professionalism Many trends

in the delivery of health care tend to make medical care impersonal.

These trends, some of which have been mentioned already, include (1)

vigorous efforts to reduce the escalating costs of health care; (2) the

growing number of managed-care programs, which are intended to

reduce costs but where the patient may have little choice in selecting

a physician; (3) increasing reliance on technological advances and

6PART 1 The Profession of Medicine

computerization; and (4) the need for numerous physicians and other

health professionals to be involved in the care of most patients who are

seriously ill.

In light of these changes in the medical care system, it is a major

challenge for physicians to maintain the humane aspects of medical

care. The American Board of Internal Medicine, working together with

the American College of Physicians–American Society of Internal Medicine and the European Federation of Internal Medicine, has published a

Charter on Medical Professionalism that underscores three main principles in physicians’ contract with society: (1) the primacy of patient welfare, (2) patient autonomy, and (3) social justice. While medical schools

appropriately place substantial emphasis on professionalism, a physician’s personal attributes, including integrity, respect, and compassion,

also are extremely important. In the United States, the Gold Humanism

Society recognizes individuals who are exemplars of humanistic patient

care and serve as role models for medical education and training.

Availability to the patient, expression of sincere concern, willingness

to take the time to explain all aspects of the illness, and a nonjudgmental attitude when dealing with patients whose cultures, lifestyles,

attitudes, and values differ from those of the physician are just a few

of the characteristics of a humane physician. Every physician will,

at times, be challenged by patients who evoke strongly negative or

positive emotional responses. Physicians should be alert to their own

reactions to such situations and should consciously monitor and control their behavior so that the patient’s best interest remains the principal motivation for their actions at all times.

Another important aspect of patient care involves an appreciation

of the patient’s “quality of life,” a subjective assessment of what each

patient values most. This assessment requires detailed, sometimes

intimate knowledge of the patient, which usually can be obtained only

through deliberate, unhurried, and often repeated conversations. Time

pressures will always threaten these interactions, but they should not

diminish the importance of understanding and seeking to fulfill the

priorities of the patient.

■ EXPANDING FRONTIERS IN MEDICAL PRACTICE

The Era of “Omics” In the spring of 2003, announcement of

the complete sequencing of the human genome officially ushered in the

genomic era. However, even before that landmark accomplishment, the

practice of medicine had been evolving as a result of insights into both

the human genome and the genomes of a wide variety of microbes. The

clinical implications of these insights are illustrated by the complete

genome sequencing of H1N1 influenza virus in 2009 and even faster

sequencing of COVID-19 in early 2020, leading to the swift development and dissemination of effective vaccines. Today, gene expression

profiles are being used to guide therapy and inform prognosis for a

number of diseases, and genotyping is providing a new means to assess

the risk of certain diseases as well as variations in response to a number of drugs. Despite these advances, the use of complex genomics in

the diagnosis, prevention, and treatment of disease is still in its early

stages. The task of physicians is complicated by the fact that phenotypes generally are determined not by genes alone but by the complex

interactions among genes and gene products, and by the interplay of

genetic and environmental factors.

Rapid progress is also being made in other areas of molecular

medicine. Epigenetics is the study of alterations in chromatin and

histone proteins and methylation of DNA sequences that influence

gene expression (Chap. 483). Every cell of the body has identical DNA

sequences; the diverse phenotypes a person’s cells manifest are, in

part, the result of epigenetic regulation of gene expression. Epigenetic

alterations are associated with a number of cancers and other diseases.

Proteomics, the study of the entire library of proteins made in a cell

or organ and the complex relationship of these proteins to disease, is

enhancing the repertoire of the 23,000 genes in the human genome

through alternate splicing, posttranslational processing, and posttranslational modifications that often have unique functional consequences.

The presence or absence of particular proteins in the circulation or

in cells is being explored for many diagnostic and disease-screening

applications. Microbiomics is the study of the resident microbes in

humans and other mammals, which together compose the microbiome.

The human haploid genome has ~23,000 genes, whereas the microbes

residing on and in the human body encompass more than 3–4 million

genes; these resident microbes are likely to be of great significance with

regard to health status. Ongoing research is demonstrating that the

microbes inhabiting human mucosal and skin surfaces play a critical

role in maturation of the immune system, in metabolic balance, in

brain function, and in disease susceptibility. A variety of environmental

factors, including the use and overuse of antibiotics, have been tied

experimentally to substantial increases in disorders such as obesity,

metabolic syndrome, atherosclerosis, and immune-mediated diseases

in both adults and children. Metagenomics, of which microbiomics

is a part, is the genomic study of environmental species that have the

potential to influence human biology directly or indirectly. An example

is the study of exposures to microorganisms in farm environments that

may be responsible for the lower incidence of asthma among children

raised on farms. Metabolomics is the study of the range of metabolites

in cells or organs and the ways they are altered in disease states. The

aging process itself may leave telltale metabolic footprints that allow

the prediction (and possibly the prevention) of organ dysfunction and

disease. It seems likely that disease-associated patterns will be found

in lipids, carbohydrates, membranes, mitochondria and mitochondrial

function, and other vital components of cells and tissues. Exposomics is

the study of the exposome—i.e., the environmental exposures such as

smoking, sunlight, diet, exercise, education, and violence that together

have an enormous impact on health. All of this new information represents a challenge to the traditional reductionist approach to medical

thinking. The variability of results in different patients, together with

the large number of variables that can be assessed, creates challenges

in identifying preclinical disease and defining disease states unequivocally. Accordingly, the tools of systems biology and network medicine

are being applied to the enormous body of information (“big data”)

now obtainable for every patient and may eventually provide new

approaches to classifying disease. For a more complete discussion of

a complex systems and network science approach to human disease,

see Chap. 486.

The rapidity of these advances may seem overwhelming to practicing physicians; however, physicians have an important role to play in

ensuring that these powerful technologies and sources of new information are applied judiciously to patient care. Since omics are evolving so

rapidly, physicians and other health care professionals must engage in

continuous learning so that they can apply this new knowledge to the

benefit of their patients’ health and well-being. Genetic testing requires

wise counsel based on an understanding of the value and limitations of

the tests as well as the implications of their results for specific individuals. For a more complete discussion of genetic testing, see Chap. 467.

The Globalization of Medicine Physicians should be cognizant

of diseases and health care services beyond local boundaries. Global

travel has critical implications for disease spread, and it is not uncommon for diseases endemic to certain regions to be seen in other regions

after a patient has traveled to and returned from those regions. The

outbreak of Zika virus infections in the Americas is a cogent example

of this phenomenon. In addition, factors such as wars, the migration of

refugees, and increasing climate extremes are contributing to changing

disease profiles worldwide. Patients have broader access to unique

expertise or clinical trials at distant medical centers, even those in other

countries, and the cost of travel may be offset by the quality of care at

those distant locations. As much as any other factor influencing global

aspects of medicine, the Internet has transformed the transfer of medical information throughout the world. This change has been accompanied by the transfer of technological skills through telemedicine and

international consultation—for example, interpretation of radiologic

images and pathologic specimens. For a complete discussion of global

issues, see Chap. 472.

Medicine on the Internet On the whole, the Internet has had a

positive effect on the practice of medicine; through personal computers,

a wide range of information is available to physicians and patients