Population healthcare including patients Inaugural lecture Marie-Louise Essink on December 11, 2013
Summary
All patients deserve equal chances on optimal healthcare outcomes. This implies that healthcare provision needs to be adapted to the needs determined by ethnic origin, educational level and social circumstances of patients. In the Academic Medical Center, University of Amsterdam, The Netherlands, we teach medical students to provide care that is responsive to patients’ needs related to diversity characteristics such as ethnic origin; ‘diversity responsive care’. We do research to identify good practice in diversity responsive care, and we identify issues for further improvement. The HELIUS study (Healthy Life in an Urban Setting) provides important opportunities for studies on equity in health and healthcare. Diversity responsive care fits in a system of population healthcare, i.e. healthcare for the population as a whole, including patients. A system of population healthcare implies great emphasis on prevention, to keep the population healthy. Patients are part of the population at large. Because the population’s burden of disease is largely determined by chronic conditions, many of us become patients at some point in life. Increasing numbers of patients have to live their lives with disease. Caring for the population as a starting point for the healthcare system has implications for medical practice, research and education. Population healthcare requires effective collaboration between curative and public health services. Because all doctors will be working from a public health perspective, every physician must be trained in thinking from that perspective.
Mission Social Medicine, in particular in relation to curative care
The headlines of a Dutch newspaper in 2012 read (De Volkskrant , June 20, 2012 ): ‘Higher educated cancer patient gets better treatment’.
4
PhD student Mieke Aarts had found evidence for differences in the quality of cancer care between cancer patients with a high and a low educational level. As a result, low-educated men with prostate cancer, with similar disease severity, had a lower chance of cure than prostate cancer patients with a high educational level. High education
Low education
Surgery
30%
20%
Brachytherapy
18%
11%
Alive after 10 years
67%
44%
Table 1. Type of care and survival of men with prostate cancer by educational level (Aarts, 2013)
Of higher educated men with prostate cancer 30 percent had surgery, compared to 20 percent of the lower educated men (see Table 1). Eighteen percent of highly educated patients were treated with internal radiation therapy, compared to 11 percent of the lower educated men.
After ten years, 67 percent of highly educated patients were still alive. Among the lower educated this was 44 percent (Aarts , 2013). The Dutch Cancer Foundation (KWF Kankerbestrijding) was shocked. A small media storm occurred. As for me, I was surprised about the shock effect of these results. That Dutch women with breast cancer and a lower socioeconomic status had a worse prognosis had already been shown in 1995 (Schrijvers, 1995). In fact, it is common knowledge that higher educated patients have more abilities to navigate the healthcare system, are better informed, are more assertive. But is it acceptable that the higher educated get better care than the lower educated? And if it is not, what can be done about it? The mission of my professorship is entitled 'Social medicine, particularly in relation to curative care’. In the first part of this lecture I will talk about equal opportunities in health care, or equity in healthcare. I will show you that social medicine and public health offer solutions to problems relating to inequity in healthcare. However, social medicine has more to offer. In the second part of my lecture I will show how important it is that each care provider acts from the perspective of social medicine, i.e., a public health perspective. Population healthcare is the best strategy to keep the population healthy.
Inaugural lecture Marie-Louise Essink on December 11, 2013
Equity in healthcare Scientific research on (un)equal opportunities in healthcare Equity in healthcare involves equal chances of good outcomes of care. Given equal disease severity, survival should be the same and not depend on education, income, ethnicity or social circumstances. Whether that holds needs to be scientifically investigated. In the United States, many studies have analyzed potential inequalities in health outcomes of care by educational level or ethnicity. In the Netherlands, such studies are scarce. It is not easy to analyze health outcomes of care by ethnicity or educational level, because the relevant patient characteristics are not routinely included in patient records. However, there is a lot of attention to quality of care in general. We then look into the ‘average’ quality of care. The next question is whether the quality of care is equally distributed among lower and higher educated patients. Is the chance of a good outcome of care for a lower educated person equal to the chance of the higher educated patient in the adjacent bed? Such questions are seldom asked.
Figure 1. Quality of care by level of education
The left panel of figure 1 shows an equal distribution of quality of care across educational levels. The right-hand panel shows lower quality of care for patients with a low educational level, and higher quality of care for patients with a high educational level.
Equity in healthcare Equity in healthcare means equal access to and quality of care across population subgroups. It is a separate criterion for the quality of every healthcare system, as well as effectiveness, safety, responsiveness, and efficiency (Murray, 2000).
Population healthcare, including patients
5
What is 'equity' in health care? What does equity in healthcare mean exactly? It means that two patients with the same condition and the same severity of the disorder also have equal opportunities for optimal treatment outcome. In the definition of Whitehead and Dahlgren ‘equal care for equal need’ (Whitehead, 2000). If patients with similar needs for care receive the same care the condition for horizontal equity is met.
6
Equal care for equal need does not mean that everyone should necessarily get the same treatment. It can also mean that unequal treatment is necessary: 'unequal care' for ‘unequal need', or vertical equity (Starfield, 2011). The crucial issue is: equal opportunities for optimal treatment outcomes. I will illustrate this by an example. Research has shown that hypertension in people of West African ancestry responds differently to drugs than in people of European origin (Brewster, 2013). In people of African-Surinamese or Antillean origin blood pressure control is often difficult to reach with antihypertensive medication that works generally well with ethnic Dutch hypertensive patients. It is therefore logical to treat people of West-African origin with hypertension differently than the ethnic Dutch.
It is therefore medically relevant to make a distinction between patients on the basis of ethnicity. Good quality of care means unequal treatment. ‘One size does not fit all'. It often does, but not on every occasion. Please note that ethnicity in this example is a crude method to make a distinction that is probably based on genetic and epigenetic characteristics. If we will get a better understanding of the causes of the differences in drug response between Europeans and Africans, we may not need ethnicity anymore.
Call for a good translation In Dutch, the word ‘equity’ is often left untranslated. The Dutch Central Planning Office (CPB) used the word 'care solidarity', defined as ‘the aim to provide the same quantity and quality of care to subjects with the same care needs’ (Ewijk van 2013). That is close to Whitehead's definition of equitable healthcare, but the CPB only used the concept in relation to the financial accessibility of the basic healthcare package. The CPB concluded the financial accessibility of the basic healthcare package in the Netherlands to be equal and good.
Inaugural lecture Marie-Louise Essink on December 11, 2013
Please think once more of the higher educated prostate cancer patients from the beginning, who received better care than their lower educated colleagues. If cancer patients with the same tumor stage in The Netherlands do not get similar treatment, the issue at stake is probably not financial accessibility. Maybe certain treatment options are less frequently offered to lower educated patients? Or maybe some treatment options are less often taken by people with lower education? And if less educated patients would decide not to accept certain treatment options, would that decision always be well-informed? For inequities in health care by educational level or ethnic origin, a proper Dutch translation seems to be lacking. How can something be an important topic in research, education and policy if we do not have a word for it? I urge all my Dutch colleagues to come up with an appropriate term.
Process versus outcome Equal chances of optimal outcomes of care, regardless of educational level, socioeconomic status, or ethnic origin. In the Netherlands there is evidence to support the presence of problems in the process of care for patients with a lower educational level or a non-Western ethnic origin.
The communication is often difficult because of a language barrier or because the doctor speaks in jargon. Or the social conditions make it difficult for the patient to stick precisely to the doctor’s prescriptions and recommendations. The issue at stake is whether such problems in the process of care also translate into unequal health outcomes. In the United States ethnic and socioeconomic disparities in health outcomes have been convincingly demonstrated, and the contribution of deficiencies in care to these has been shown as well. Also in the Netherlands, socioeconomic and ethnic disparities in healthcare outcomes were demonstrated. The research group of Steegers and Bonsel from Rotterdam found an increased risk of perinatal mortality in large cities (Poeran, 2013). Living in a deprived neighbourhood is an additional risk factor, especially for low-educated ethnic Dutch women. In part, deficiencies in care were to blame. Perinatal care did not adequately take the knowledge and the social circumstances of these women into account. The researchers call for the introduction of 'social obstetric care’. They find that not only the medical risk factors need to be mapped, but also lifestyle and psychosocial conditions. And it does not end there, there is also an obligation to intervene.
Population healthcare, including patients
7
A recent study showed that children of mothers who smoked during pregnancy have a smaller brain volume and morphological abnormalities in the brains at the age of seven (El Marroun, 2013). The times that smoking during pregnancy could be considered as an ‘autonomous choice’ and a ‘personal responsibility’ have definitely gone.
8
A second example, from our own research. We showed that the information provision to pregnant women of non-Western origin about prenatal screening for Down syndrome was deficient (Fransen, 2009; Fransen, 2012) . The midwives tried very hard, but almost never made use of professional interpretation services and were not aware of the existence of information materials in the language of the country of origin of the pregnant women. 100 90 80 70 60
Dutch
50
Turkish
40
Surinamese
30 20 10 0
Knowledge Down syndrome
Knowledge risk assessment
Knowledge diagnostic follow-up
Such a shame. I wish we could channel all that energy so that the message comes across. I will investigate whether there are ethnic and socioeconomic inequities in quality of care, their size, which types of care, diseases or patients increase the risks, and the mechanisms behind them. Ethnic and socioeconomic inequities in quality of care do not arise because patients do not originate from The Netherlands, or because of lower educational levels. The real cause is the response of the healthcare system to patient characteristics that go associated with a non-Dutch ethnic origin or with a lower educational level. I will look for 'the cause of the cause'.
Health literacy Please think once more of the less educated prostate cancer patient from the beginning who received lower quality of care than his companion with a higher education. Those higher educated patients often navigate the healthcare system more successfully. They have better knowledge and better contacts. They also have better health literacy (Health Council of the Netherlands, 2011).
Figure 2. Ethnic differences in knowledge about prenatal screening for Down syndrome (Fransen, 2009)
Inaugural lecture Marie-Louise Essink on December 11, 2013
Health literacy refers to skills to obtain, understand and apply health information. Differences in health literacy are likely to be a major cause-of-the-cause of inequities in care by educational level and ethnic origin. Over and over again, research has shown that about 11 percent of the Dutch population is functionally illiterate, the majority of them being ethnic Dutch. 25 % are low-literate, and can just read and write enough to get by in everyday life. But these low literate people get stuck in a complex environment such as healthcare. Low health literacy is more common than many highly trained health care providers are aware of. Low health literacy is also important for effectively addressing educational differences in the quality of curative and preventive care. In the coming years we will investigate how preconception care can be adapted so that this preventive program will become accessible and effective for women with low health literacy. As for the upcoming population-based screening program for colorectal cancer, we investigate how people with low health literacy can best be supported in taking an informed decision to participate or not in the screening program, and to properly perform the tests.
Patient safety The study on ethnic differences in patient safety is another example of research into equity of care. We have conducted this study since 2010 in alliance with the VUmc. We used the medical records of ethnic Dutch and non-Western patients in hospitals in the Randstad, the most densely populated region in the Netherlands including the cities of Amsterdam, Rotterdam, The Hague and Utrecht (Van Rosse, 2012). Overall, we found no differences in patient safety between ethnic Dutch and non-Western patients (van Rosse, 2013). Qualitative interviews with caregivers and patients showed that there were problems in the care process. Language barriers hampered all security checks, such as checking the patient’s name when providing medication. But these process issues did not translate into increased patient safety risks . That is a reassuring message to Dutch hospital care! But is this really as comforting as it seems at first sight? Often hospitals had protocols to effectively overcome a language barrier, but these had been poorly implemented. Care providers tried to communicate with hands and feet first, then switched to informal interpreters such as a family member, and almost never made use of professional interpretation services.
Population healthcare, including patients
9
The role of the family of patients was interesting in other regards as well. The 2nd generation family members (often adult sons or daughters) of non-Western ethnic minority patients not only provided extra pairs of eyes and ears, but actually arranged everything for the patient. Although they apparently did surprisingly well, it does not seem rational to me to let patient safety depend partly on sons or daughters whose competencies and own interests are unknown to us.
10
The observation that problems in the care process not always translate into poorer outcomes of care is not an excuse for letting things be as they are. Patients who do not possess sufficient proficiency in Dutch or have low literacy often literally feel 'unheard', which gives them a feeling of unsafety (Suurmond , 2011). According to the new paradigm of valuebased healthcare, the important issues in care go beyond outcomes only (Gray, 2013). A good care process adds value to the healthcare used by a minority or low-literate patient. He feels heard and understood, and receives care that is consistent with his preferences. So we investigate whether or not it is justified to make distictions between patients on the basis of ethnic origin or socioeconomic status. We examine where this works well in healthcare in that respect, and identify opportunities to improve, and how.
HELIUS Existing registries such as the Dutch Cancer Registry, and the HELIUS study (‘Healthy Life in an Urban Setting’; www.heliusstudy.nl ) are essential for this area of research (Stronks 2013; Essink-Bot 2012).
Figure 3. Logo Helius study
HELIUS, initiated by the Academic Medical Centre (AMC) and the Municipal Health Service (GGD) Amsterdam, is the first multi-ethnic population-based cohort study worldwide. Last November we celebrated the inclusion of participant number 10,000. The aim is to include 5,000 participants from six ethnic groups each, so 30,000 in total. The main value lies in the combination of objective measurements; detailed information from the participant on, for example, migration history , cultural background, diet and lifestyle; and the linkage to care registries . A cohort as HELIUS is real research infrastructure and an important investment for science and public health (Health Council of the Netherlands, 2008).
Inaugural lecture Marie-Louise Essink on December 11, 2013
Figure 4. Article from Journal of University Hospital Amsterdam, Volume 11, November 1982
Strategies for solutions Figure 4 shows the front page of an issue of the Journal of the University Hospital at the University of Amsterdam from 1982. I was a 4th year medical student at that time. It reads, in translation:
"The Netherlands have become a multicultural society. The foreign 'guest' worker is not a temporary phenomenon anymore. [ .... ] Most Dutch 'tolerate' this. [ .... ] The healthcare system is generally ill-prepared to respond to the presence of these ethnic minorities [ ... ]. They tend to live in conditions that bring about all sorts of tensions, such as navigating between two cultures, poor housing, and problems in the areas of language and integration in Dutch society. [ .. ] The Dutch care provider often feels powerless. He knows too little about other languages and cultures to provide adequate care." The terminology reveals that this is an old newspaper. But beyond that, most of the text is still fully valid! It is time for a systematic approach.
Population healthcare, including patients
11
Dr. Sigmund, we have people from over 175 countries in this city!
Are you prepared to handle all these different cultural backgrounds?
I am a certified medicine man.
Yes.
Figure 5. Peter de Wit , De Volkskrant, June 20, 2013
Cultural competence (diversity responsive care) 12
Cultural competence of healthcare providers and healthcare organizations is important for good care to ethnically diverse patient populations, as currently in the Netherlands. We analyzed the precise content and meaning of ‘cultural competence’. Therefore, we now know what a care provider should know and be able to do. Cultural competence has less to do with ‘culture’ than the term suggests. Some knowledge of non-Western religious or nonreligious habits is useful. But the cultural variation within countries of origin is at least as large as the cultural variation within the Netherlands. Knowledge of 'the Turkish culture' can easily lead to stereotype and biased behaviour.
An open attitude, genuine interest, understanding of the role of the (ethnic) origin of the physician himself plays in the interaction with the patient, and the ability to find out about the patient perspective on the disease and his expectations from the treatment in a respectful way, are much more important than cultural knowledge. These are in fact general skills required for 'patient-centered care'; students learn these in their training as physicians. Good quality of care to diverse populations places extra demands on patient-centered care: ‘patient-centered-PLUS’ (Seeleman, 2009; Seeleman, 2012; Seeleman, 2014). We therefore think ‘culturally competent care’ less satisfactory as a term. But what could be the more appropriate alternative? ‘Diversity responsive care’? Again this is a call to you all to come forwarde with a better term.
Inaugural lecture Marie-Louise Essink on December 11, 2013
But whatever the name, effective communication with the patient is essential, and thus the ability to effectively handle any language barrier. Every person permanently staying in The Netherlands has to learn Dutch, but such a policy does not solve the problem in the consultation room. Underuse of professional interpretation services, even in the days when they were still paid for by the government, is a real problem. According to the Law on the Medical Treatment Contract (Wet op de Geneeskundige Behandelings Overeenkomst) it is the responsibility of the care provider to communicate ‘in a form that is understandable to the patient’ (Meeuwesen, 2011; Fransen, 2013).
Patients with a mother tongue other than Dutch and their care providers may be insufficiently aware of this clear obligation. It is not true that engaging an interpreter takes a lot of time, the language barrier takes time, not the interpreter. The use of a bilingual staff members without formal training in interpretation skills in non-acute situations is risky and contrary to for example the JCI standards. Skipping history taking and applying 'veterinary medicine' is explicit discrimination (van de Vathorst 2013).
Education in culturallycompetent care 13
He says AA
Please go back to the 1982 newspaper (Figure 4). Initiatives had been taken to improve 'the care for foreigners ' in the Academic Hospital of the University of Amsterdam, mostly focused on nursing care. At the very end one of the pioneers said: "By the way, the Board also sent a request to AMC Medical School to pay more attention to the ‘phenomenon of foreign patients’ “.
Figure 6. Canary Pete. Medisch Contact, January 27, 2012
That should of course be more than an afterthought. Medical education is in fact an excellent strategy to implement changes in healthcare, albeit in the long term.
Population healthcare, including patients
14
We work on the integration and implementation of the Longitudinal Thread Diversity in the Bachelor and Master of Medicine at the University of Amsterdam. In the AMC all novice interns receive training in addressing a language barrier and effectively work with an interpreter. The coming two years, we conduct the European funded C2ME project ('Cultural Competence in Medical Education’; http://www.amc.nl/C2ME) to develop Teach the Teacher materials to educate teachers and enhance their skills for diversity training. If the role models for medical students do not know how to overcome a language barrier , we cannot expect that the intern will phone the interpreter services. I am glad with our colleagues from VUmc participating in the consortium. We have a large expertise in the field of diversity education, that I want to sheaf in a Center for Figure 7. Textbook ‘A doctor in the world’, 2nd edition 2012 Diversity in Medical Education.
Doctors have more difficulties caring for patients who are less like them, in terms of age, sex, educational level, socioeconomic status, ethnic origin.The strange thing is that it is quite accepted to distinguish between patients by age. No doctor gives a child aged 6 the same as someone aged 80. But for male / female, socioeconomic status and ethnicity there are apparently more difficulties. In the Academic Medical Center Amsterdam, we want to teach the young doctor how he or she can effectively respond to diversity in the patient population. I will name a few milestones. The first is a Dutch textbook on ethnic diversity in healthcare: ‘A doctor in the world’, based on casuistry from day-today medical practice, which appeared in the second edition in 2012 (Suurmond, 2012).
Inaugural lecture Marie-Louise Essink on December 11, 2013
Population healthcare So far I shared with you my vision and plans regarding equity in healthcare. Professionalization of the ways to respond effectively to varying ethnic origins and socioeconomic conditions in curative care is one of the contributions of social medicine to curative healthcare. I now want to put this into a broader perspective: what else may social medicine contribute to future healthcare? And has the time now come to substantiate those contributions?
Forecasts of medical professions In 2012, the medical specialists, general practitioners and public health physicians each published a forecast (Project The Medical Specialist, 2012; LHV / NHG, 2012 ; KAMG, 2012). I am a public health physician myself (in Dutch: arts Maatschappij en Gezondheid).
Those forecasts were deemed necessary because of the challenges the healthcare system is facing, including an ageing population, care needs determined by chronic diseases and multimorbidity, and the sustainability of the system itself. The GP report also mentions that increasing diversity in the population contributes to changing demand for healthcare. The forecasts are then remarkably consentient. All three express a need for more prevention. Prevention has always been a core activity of social medicine. And all three emphasize the need for cooperation in care, both within the healthcare system, but also with partners outside the healthcare system, such as the municipality. Both forms of cooperation are familiar territory for social medicine. The GPs explicitly name the pursuit of equal opportunities in health (equity). Explicit attention to vulnerable groups is a core value of social medicine.
Population healthcare, including patients
15
16
What is social medicine?
Population healthcare
That brings us to the definition of social medicine. Social medicine is the branch of medicine that deals with public health (the English term is often left untranslated in Dutch). The Dutch textbook ‘Population health and the healthcare system’ refers to 'public health' as the collective complement of individual patient care (Mackenbach, 2012). We recently reformulated an objective and essential functions of public health based on international literature (Jambroes, 2013). Public health focuses on promoting health and equal opportunities in health, and makes use of collective measures to achieve these goals. Prevention is a key element. To give you an idea, about 10 percent of the 30,000 registered physicians in the Netherlands holds a registration in social medicine. Of those 3,000, about 2,000 hold a registration in occupational and insurance medicine, and about 1,000 hold a registration in the branch to which I belong, that of the physician ‘Society and Health’. There are also so-called profile registered physicians who had a shorter practice specialization.
Following my thesis, curative doctors will need more social medicine to be able to fulfill their role in the future healthcare system. The first Professor of Social Medicine at this university, Arie Querido, was appointed in 1961 and pleaded for just that purpose. He was a psychiatrist in the city of Amsterdam and saw every day the effects of poor living conditions on people's health. He advocated ‘integrative medicine’, care that effectively takes into account people’s psychological characteristics and socioeconomic conditions. If the onset of disease is a result of the interaction of physical, psychological and social factors, then it seems only logical to take into account all three in healthcare as well.
Figure 8. Population Healthcare (figure made by Kim Rauwerda)
Inaugural lecture Marie-Louise Essink on December 11, 2013
The term 'population medicine' recently resurfaced in the international literature (Gray, 2013). I translated it with 'population healthcare', a term that was used for the first time in The Netherlands in 1997 by Louise Gunning (Scientific Council, 1997). In my interpretation, population healthcare involves a healthcare system for the population as a whole. Population healthcare is committed to maximizing health and its distribution for the entire population that we serve. Patients are part of the population. However, there is much emphasis on prevention, ‘keep the population healthy’. Since the burden of disease is determined primarily by chronic diseases, many people become patients at some point in time. More and more people are living with disease, and shape their daily lives with the disease. Population healthcare effectively keeps account of the living conditions of citizens.
What does population healthcare look like? Several authors explicitly argued in recent years in the literature to include more 'public health and preventive medicine' in care. I show you Levy and Wegman’s paper from 2012 (Levy, 2012). Where ‘public and preventive care’ (public health) and ‘medical care’ (the curative sector) currently operate in largely separated fields with limited overlap, they argue that curative care should rather be provided in the context of public health (see Figure 9). And that fits perfectly with the aforementioned visions of specialists and general practitioners. The time has come for the public health perspective in curative care, since this is in line with the visions on the future of the curative sector itself.
Figure 9. Public health and the curative sector Levy BS, Wegman DH. Public Health and preventive medicine. Academic Medicine 2012; 87:837-9
Population healthcare, including patients
17
What does this mean for the curative doctor?
18
We remain with Levy & Wegman’s Figure B. We take general practice as an example ( see Figure 10 ). These generalists are on the edge of the inner circle, but still on the inside. However, on the website of a primary care center in the ‘Schilderswijk’ in The Hague, we read the motto: "Working together for your health". The text continues: "High-quality [care] tailored to the needs of the residents of the ‘Schilderswijk’. Delivered by many different providers that cooperate where necessary. [...] Targeted prevention and care for the residents, in full width."
In this district this is pursued through explicit cooperation between public health (municipal healthcare ‘GGD’) and GP care. Two well-known projects in the districts ‘Utrecht Overvecht’ and ‘Amsterdam-Noord’ provide a second example of population healthcare. These neighbourhoods experiment with an integrated range of prevention, care and welfare (Broeke van den, 2014). In both examples, general practice 'crosses the line', see the right-hand panel in Figure 10; general practice from a public health perspective.
(www.rubenshoek.nl).
Figure 10. General practice with a public health perspective adapted from Levy and Wegman 2012
Inaugural lecture Marie-Louise Essink on December 11, 2013
Specialist care is still needed. Prevention causes delay of disease incidence, but often disease will occur anyway. Heart attacks will continue to occur and then specialized cardiac care is required. However, in a context of public health (see Figure 11). For secondary prevention of cardiovascular disease, let’s say the care to prevent it from happening again, a patient who has survived a heart attack has to take preventive medication. But in addition, he has to adopt a healthy diet, exercise a lot, and quit smoking. A study of our own in 2009 found that yes, cardiologists say that to the patient. But we know from health promotion that that is not enough. Effective strategies for lasting lifestyle change that can be applied excellently by trained nurse specialists (Jørstad, 2013) have been developed in public health.
The cardiologist rightly says that he has not been trained to provide lifestyle change. But with the public health perspective in mind, however, he provides effective referral to lifestyle counseling, near where the patient lives, and he motivates the patient to participate.
Consequences for social medicine Public health specialists will also remain necessary, in the outer circle, but in connection with the curative sector. But to truly bridge the gap between public health and the curative sector, social medicine must also leave its comfort zone.
Figure 11. Cardiology from a public health perspective adapted to Levy and Wegman, 2012
Population healthcare, including patients
19
To begin with, we as a profession need to become a clear discussion partner for the curative colleagues. Therefore, we Dutch public health physicians (‘artsen M&G’) should focus on what unites us and not on what divides us.
Consequences for medical training
20
Of course, the public health perspective also has implications for basic medical training. An American author recently suggested that medical education is wrongly targeted: "The goal of medical education is not simply to produce physicians. It is to improve the health of patients and their communities” (Lucey, 2013).
The ‘sovereign personally expert physician’ who acted like a ‘self-contained clinical microsystem’ has long been the starting point for medical training. However, the doctor who only takes into account the individual patient is a doctor of the past. With chronic multiple problems, only effective multidisciplinary collaboration within the health care system but also literally across the walls can help us. And taking into account the social environment in which the patient who, once outside the care institutions, needs to shape his life with disease.
Figure 12. The place of academic public health adapted from Levy and Wegman, 2012
Inaugural lecture Marie-Louise Essink on December 11, 2013
The role of 'academic' public health Where can we find the 'academic' public health, i.e., my own workplace at the department of Social Medicine at the AMC? See Figure 12.
Curative care and social medicine are in fact virtually separated fields. And academic public health may have become a little detached from her own practice. To solve the latter problem, we have now the Academic Collaborations for Public Health (www.awpg.nl).
Figure 12 shows that I hope that academic public health is in the current situation located in the overlapping part of the two circles. However, I am afraid that in real life the ‘X’ should be placed outside the circles, and that the circles are in fact farther apart, see Figure 13.
21
Figure 13. Another place for academic public health adapted from Levy and Wegman, 2012
Population healthcare, including patients
Academic public health must, see Figure 14, move to the edge of the inner circle, at the intersection of and in connection with the inner circle (cure) and the outer circle (public health practice). My chair at the Department of Social Medicine of the AMC, within the walls of the university hospital and close to the ‘Bijlmer’ is thus exactly right!
Strengthen academic social medicine
22
But then we need academic public health physicians, to saturate and inspire the minds of future generations of doctors with the public health perspective, and to generate scientific evidence to support population healthcare practice.
Thereto the University Medical Centers (UMCs) need to train academic public health physicians. The Department of Social Medicine of the AMC was the first in the Netherlands to obtain recognition as practical training site for academic public health physicians. In their practical training, they become proficient in public health research and education. In the AMC, young doctors with an interest in public health may combine their PhD with a specialization into public health physician. These young colleagues will of course be the specialists who will build bridges between public health and curative care. It is an honor for me to contribute to the training of this new generation.
Figure 14. The place that the academic public health should take adapted from Levy and Wegman, 2012
Inaugural lecture Marie-Louise Essink on December 11, 2013
Ladies and gentlemen, we are approaching the end of this public lecture. First, I shared my vision and plans regarding equity in healthcare. Professionalization of the ways to respond effectively to varying ethnic origins and socioeconomic conditions in curative care is one of the contributions of social medicine to curative healthcare. Subsequently I showed you that population healthcare has the future.
This requires effective collaboration between curative and public health services; collaboration while maintaining individuality. All doctors will be working from a public health perspective, and therefore every physician must be trained in thinking from a public health perspective.
23
Population healthcare, including patients
I wish to thank
Prof. Paul J. van der Maas Prof. Gouke J. Bonsel Prof. Karien Stronks Prof. Johan P. Mackenbach Prof. J. Dik F. Habbema Prof. Ewout Steyerberg Prof. Harry J. de Koning Prof. Hein Raat Prof. Jan Wllem Coebergh Prof. Lonneke van de Poll-Franse Prof. Sophia de Rooij Prof. Evelien Dekker Joanna Madalinska PhD Ida J. Korfage PhD Esther W. de Bekker-Grob PhD Tim Damen PhD Roderick van den Bergh PhD Karien van den Bergh PhD Mirjam Fransen PhD Marleen Schoonen PhD Majda Lamkaddem PhD Conny Seeleman MSc. Marielle Jambroes MD Floor van Rosse MSc. Eva Laan MSc. Aydin Sekercan BSc Ines Rupp Md PhD Jeanine Suurmond PhD Lizzy Brewster MD PhD Doenja Rosenmoller MSc. Nita P. Dewkali Henriette van Dijk-van de Kooi Noor Oosterhof Ed van Beeck MD PhD Hajo Wildschut MD PhD Janneke Harting PhD Anton Kunst PhD Marlies Stouthard PhD Heleen van Agt PhD Paul Krabbe PhD Martine de Bruijne MD PhD .... and many others.
References
Aarts, M.J., E.L. Koldewijn, P.M. Poortmans, J.W. Coebergh, M. Louwman. The impact of socioeconomic status on prostate cancer treatment and survival in the southern Netherlands. In: Urology, 81 (3), p. 593599. 2013 Brewster, L.M., Y.K. Seedat. Why do hypertensive patients of African ancestry respond better to calcium blockers and diuretics than to ACE inhibitors and β-adrenergic blockers? A systematic review. In: BMC Medicine, 11:141. 2013 Broeke, J. van den, T. Plochg, H. Schreurs, S. Quak, M. Egberts, E. van der Vorst, A. Verhoeff, K. Stronks. Wat is de werkwijze van zorg- en welzijnsorganisaties in Utrecht en Amsterdam om de hoge zorgconsumptie in achterstandswijken te verlagen? In: Tijdschrift voor Sociale Geneeskunde, in druk. 2014 De Volkskrant. 20 juni 2012 El Marroun, H., M.N. Schmidt, I.H. Franken, V.W. Jaddoe, A. Hofman, A. van der Lugt, F.C. Verhulst, H. Tiemeier, T. White. Prenatal Tobacco Exposure and Brain Morphology: A Prospective Study in Young Children. In: Neuropsychopharmacology, p. 1-9. 2013 Essink-Bot, M.L., M. Lamkaddem, P. Jellema, S.S. Nielsen, K. Stronks. Interpreting ethnic inequalities in healthcare consumption: a conceptual framework for research. In: European Journal of Public Health, 23, (6), p. 922-926. 2013 Ewijk, C. van, A. van der Horst, B. Besseling. Gezondheid loont – tussen keuze en solidariteit. Boek 7 in Toekomst voor de zorg. Den Haag: Centraal Planbureau. 2013 Fransen, M.P., H.I.J. Wildschut, I. Vogel, J.P. Mackenbach, E.A.P. Steegers, M.L. Essink-Bot. Information about prenatal screening for Down syndrome. Ethnic differences in knowledge. In: Patient Education and Counseling, 77, p. 279-288. 2009 Fransen, M.P., H.I.J. Wildschut, J.P. Mackenbach, E.A.P. Steegers, M.L. Essink-Bot. Midwives unable to overcome language barriers in prenatal care. In: Italian Journal of Public Health, 9, (3). 2012
Population healthcare, including patients
27
Fransen, M.P., V. Harris, M.L. Essink-Bot. Beperkte gezondheidsvaardigheden bij patienten van allochtone herkomst- een tolk inzetten is vaak niet genoeg. In: Nederlands Tijdschrift voor Geneeskunde, 157, A5581. 2013 Gezondheidsraad. Laaggeletterdheid te lijf. Signalering ethiek en gezondheid, 2011/1. Den Haag: Centrum voor ethiek en gezondheid. Publicatienummer Gezondheidsraad: 2011/17. 2011 ISBN978-9078823-00-1 Gray, J.A. The shift to personalised and population medicine. In: Lancet, 382, (9888), p. 200-201. 2013 Jambroes, M., M.L. Essink-Bot, T. Plochg, B. Zaadstra, K. Stronks.De Nederlandse publieke gezondheidszorg – 10 kerntaken en een nieuwe definitie. In: Nederlands Tijdschrift voor Geneeskunde, 157, A6195. 2013
28
Jorstad, H.T., C. von Birgelen, A.M. Alings, A. Liem, J.M. van Dantzig, W. Jaarsma, D.J. Lok, H.J. Kragten, K. de Vries, P.A. de Milliano, A.J. Withagen, W.J. Scholte Op Reimer, J.G. Tijssen, R.J. Peters. Effect of a nursecoordinated prevention programme on cardiovascular risk after an acute coronary syndrome: main results of the RESPONSE randomised trial. In: Heart, 99, (19), p. 1421-1430. 2013 KAMG (Koepel Artsen Maatschappij en Gezondheid). De bevolking gezond houden – position paper. Artsen, Maatschappij & Gezondheid. December. 2012 http://medischcontact.artsennet.nl/actueel/federatienieuws/federatiebericht/129001/kamg-brengtposition-paper-uit.htm Levy, B.S., D.H. Wegman. Public Health and preventive medicine. In: Academic Medicine, 87, p. 837-839. 2012 LHV/NHG. Toekomstvisie huisartsenzorg. Modernisering naar menselijke maat. Huisartsenzorg in 2022. Utrecht: LHV/NHG. 2012 http://www.tkv2022.nl/wp-content/uploads/2012/11/LHV001-37-ToekomstvisieTotaal-Binnenwerk_021112_WWW.pdf
Inaugural lecture Marie-Louise Essink on December 11, 2013
Lucey, C.R. Medical education: part of the problem and part of the solution. In: JAMA Internal Medicine, 173, (17), p. 1639-1643. 2013 Mackenbach, J.P., K. Stronks, (ed). Volksgezondheid en gezondheidszorg. 6e druk. Amsterdam: Reed Business. 2012 ISBN 978-90-352-34451 Meerwaarde. De meerwaarde van Academische werkplaatsen Publieke Gezondheid voor gemeentelijk gezondheidsbeleid. 1 februari. 2013 http://www.youtube.com/watch?v=rmJQOSY5ShM Meeuwessen, L., H. Harmsen, A. Sbiti. Als je niet begrijpt wat ik bedoel -Tolken in de gezondheidszorg. Rotterdam: Mikado. 2011 ISBN: 978-90-77782-22-4 Murray, C.J., J. Frenk. A framework for assessing the performance of health systems. In: Bulletin of the World Health Organization, 78, (6), p. 717-731. 2000 Poeran, J., A.F. Maas, E. Birnie, S. Denktas, E.A. Steegers, G.J. Bonsel. Social deprivation and adverse perinatal outcomes among Western and non-Western pregnant women in a Dutch urban population. In: Social Science Medicine, 83, p. 42-49. 2013 Projectgroep De Medisch Specialist 2015. De Medisch Specialist 2015. Visiedocument. Utrecht. 2012 http://www.internisten.nl/uploads/Gy/_0/Gy_0ebiR1weG-Ubet7Y6PQ/2015-medisch-specialist--samenvatting1.pdf Raad voor Gezondheidsonderzoek. Van gegevens verzekerd. Kennis over de volksgezondheid in Nederland nu en in de toekomst. Den Haag: Gezondheidsraad. 2008 RGO nr. 58 ISBN978-90-5549-730-0. www.gr.nl Rosse, F. van, M.C. de Bruijne, C. Wagner, K. Stronks, M.L. Essink-Bot. Design of a prospective cohort study to assess ethnic inequalities in patient safety in hospital care using mixed methods. In: BMC Health Services Research, 7, 12:450. 2012
Population healthcare, including patients
29
Rosse, F. van, M.C. de Bruijne, M.A. Broekens, K. Stronks, M.L. Essink-Bot, C. Wagner. Etnische herkomst en zorggerelateerde schade. Rapport. Amsterdam: EMGO+ Instituut, AMC en NIVEL. 2013 www.patientveiligheid.nl Seeleman, C., J. Suurmond, K. Stronks. Cultural competence: a conceptual framework for teaching and learning. In: Medical Education, 43, (3), p. 229-237. 2009 Seeleman, C., K. Stronks, W. van Aalderen, M.L. Essink-Bot. Deficiencies in culturally competent asthma care for ethnic minority children: a qualitative assessment among care providers. In: BMC Pediatrics, 12:47. 2012 Seeleman, M.C. Cultural competence and diversity responsiveness: how to make a difference in healthcare? Proefschrift. Amsterdam: UvA. 2014 Schrijvers, C.T.M., J.W.W. Coebergh et al. Socioeconomic status and breast cancer survival in The Southeastern Netherlands 1980-1989. In: European Journal Cancer, 31A, (10), p. 1660-1664. 1995 30 Starfield B. The hidden inequity in health care. In: International Journal For Equity in Health. 10:15. 2011 Stronks, K., M.B. Snijder, R.J. Peters, M. Prins, A.H. Schene, A.H. Zwinderman. Unravelling the impact of ethnicity on health in Europe: the HELIUS study. In: BMC Public Health. 13:402. 2013 Suurmond, J., E. Uiters, M.C. de Bruijne, K. Stronks, M.L. Essink-Bot. Negative health care experiences of immigrant patients: a qualitative study. In: BMC Health Services Research, 11:10. 2011 Suurmond, J., C. Seeleman, K. Stronks, M.L. Essink-Bot. Een arts van de wereld – etnische diversiteit in de medische praktijk. Tweede druk. Houten: Bohn Stafleu Van Loghum. 2012 ISBN 978-90-313-9146-2 Vathorst, S. van de, D. Willems, M.L. Essink-Bot. The contribution of the capabilities approach to reconciling culturally competent care and nondiscrimination. In: The American Journal of Bioethics, 13, (8), p. 47-48. 2013
Inaugural lecture Marie-Louise Essink on December 11, 2013
Author m.l.essink-bot@amc.uva.nl DTP e.wiggemansen@zonnet.nl Nothing from this publication may be used without prior agreement to do so from the author.
Marie-Louise Essink-Bot MD PhD was appointed as a Professor in Social Medicine, in particular in relation to curative care, at the Faculty of Medicine at the University of Amsterdam, the Netherlands.