BY: ANN STOCKHO
Healthcare providers — whether physicians, nurses, managers, administrators, or large institutions — have a unique way of knowing things, proposed Deborah Prothrow-Stith, MD, at the Medical Group Management Association's annual conference in October. This unique way of knowing comes from their special position in the community, their contact with patients, and their firsthand experience with the consequences of social and public health problems. And this special knowledge, Prothrow-Stith continued, must become part of our public policy discussion and efforts at prevention of teenage violence.
If one is drawn to work in healthcare, "I believe it is in your nature to do good," said Prothrow-Stith, assistant dean for government and community programs at Harvard School of Public Health, Boston, and the author of Deadly Consequences: How Violence Is Destroying Our Teenage Population and a Plan to Begin Solving the Problem. To be true to that nature, she said, we have to look at how healthcare providers can help fulfill the public health mission and at how public health is going to help with issues of healthcare delivery.
Teenage Violence as a Public Health Problem
Prothrow-Stith described her frustration as an intern and resident at Boston's Women's Hospital 20 years ago, where she saw evidence of many societal problems that had a direct impact on health.
"I would stitch people up and send them out, knowing that they were going to get involved in another episode of violence," she said. Her young patients in the emergency room would tell her that they were going to get revenge and send someone else to the hospital to get stitches.
"I felt frustrated that we didn't have a prevention protocol," Prothrow-Stith recalled. That frustration sparked her interest in adolescent violence. She learned homicide was the leading cause of death for adolescent males growing up in urban poor communities, and the second leading cause of death for all adolescents in this country. "I was frustrated because as a clinician I had not been trained to prevent what was a major problem for the population."
This frustration led to her work in public health; over the past 20 years "I moved from being a 100 percent clinician to being a 100 percent public health practitioner," said Prothrow-Stith. But attitudes toward violence 20 years ago were not what they are today. At first, Prothrow-Stith said, defining violence as a public health problem was considered "a bit bizarre. When I tried to do my senior resident lecture on homicide and violence, I was told it was not an appropriate topic." Now, two decades later, hospitals all over the country are holding programs on this issue. Prothrow-Stith hopes that the same sort of shift in attitude can take place for other problems, too.
Prothrow-Stith's emergency room experience taught her that healthcare providers' "contact with victims and the perpetrators of violence was very special . . . and demanded a response . . . . We have a unique contact with people that allows us to add something different to the spectrum." This makes it our responsibility to be true to our nature to do good and contribute to the public policy debate, to "participate in the public good in a way that allows us to use what we know."
Violence Requires an Interdisciplinary Approach
Prothrow-Stith described violence as "not a typical healthcare problem." Its prevention requires contributions from the media, educators, and parents, and also multiple strategies. As a clinician, Prothrow-Stith had a paradigm of primary, secondary, and tertiary prevention to offer. Taking lung cancer as an example, Prothrow-Stith explained that primary prevention is "what we do to change attitudes." To change public perception of smoking as glamorous to smoking as undesirable is primary prevention. The same shift in attitudes is necessary to reduce violence.
Secondary prevention is "what we do to help people who smoke stop smoking:" clinics, behavior modification, and the like. In violence, secondary prevention is aimed at children at greater risk, who tend to be urban, poor, and male. Most at risk are those who witness violence or are victims of violence in early childhood. The special knowledge of healthcare delivery can be used for secondary prevention strategies against violence, to begin addressing the problem earlier, Prothrow-Stith said.
Tertiary prevention is the treatment. For lung cancer, it may be chemotherapy or surgery; in violence, this can be the treatment a victim's family, siblings, or peers receive at the hospital, as well as the treatment the victim receives. "That special contact, even in the emergency room, becomes very important," said Prothrow-Stith.
Taking Risks
How can violence-prevention strategies serve healthcare practices without having a negative effect on the bottom line? "We can mutually benefit from working on violence and other issues," said Prothrow-Stith. She told of a doctor who, at the six-week well-baby check, asks parents about the way they argue, and how they plan to discipline their child. "He writes actual prescriptions for parents to read to their child every night for 15 minutes, or to turn off the television set two or three nights a week," Prothrow-Stith said. "What else could we write prescriptions for?" Doctors could write prescriptions for voting, or for civic participation, she suggested. "We know people are healthier if there is social participation and interaction." Writing a prescription might be a way to start someone thinking about participating in the community, and we need to think of other things we can do, too, she said. "The challenge is to take a little risk — not a huge risk; to take small steps that allow us to claim our role in changing the situation."
—Ann Stockho