Prevenção quaternária: as bases para sua operacionalização na relação médico-paciente

Abstract

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

Geoffrey Rose e o princípio da precaução: para construir a prevenção quaternária na prevenção

“…The more a clinical outcome becomes acknowledged to be avoidable by additive prevention, the greater the need for PP and P4 19 . The complexity of the health-disease processes is great and the theoretical models underlying these measures are always to some degree reductionist and limited.…”

“…The P4 in PHC is a necessity 18 . In clinical care, it can be operated through the interpretation of clinical contexts and negotiation of treatments via: (a) the use of judicious words; (b) the adoption of dynamic explanatory models in handing out professional interpretations (diagnoses) to patients; (c) the singularization of therapies; and (d) the distinction between present/future disease clinical care, i.e., care of an ill person versus future disease (prevention) 19 . This distinction is crucial for P4 in prevention 7 .…”

Following McWhinney’s footsteps: from family medicine to traditional and complementary medicine

“…This includes clinical contexts of medically unexplained symptoms (MUS), functional disorders such as irritated bowel syndrome, dyspepsia, pains (headaches, back pains), and mental health problems (depression, anxiety, etc). In summary, the gradient of biomedical EMs loses predictive power and generalisation as it moves away from well-defined (anatomopathological) towards poorly defined (semiological) clinical disease frameworks 37 . In all these contexts, illness is present as concrete facts that individualise each clinical case.…”

Prevenção quaternária: um olhar sobre a medicalização na prática dos médicos de família

“…However, between these extremes there is an array of clinical conditions with semiological expression of complex and undefined signs/symptoms that also require intense P4 actions (quadrant 4 in Figure 2). 25,47 This analysis points to the differences between "preventive contract" and "curative contract" in the clinical relationship and P4 activities: limiting damage and reducing interventions in preventive actions are compelling ethical duties (prevention tolerates no damage), while curative actions carry a higher damage tolerance threshold, justified by the intention to recover health. 42 Quaternary prevention also highlights the importance of the doctor-patient relationship by: (a) recognising person's uniqueness and autonomy; (b) valuing a shared decision-making process; (c) adopting a clinical method focused on the person; 10 and (d) developing relational and communicational skills in the clinical encounter, that can result either in medicalization or coproduction of health and autonomy.…”

“…Norman and Tesser 47 propose guidelines for P4 operationalization in the practice of family and community doctors. According to the authors, the more the potential for people's suffering is projected into the "future" the more the need for P4 actions, thus indicating a hierarchy of these actions.…”