Curative and population medicine: bridging the great divide

There are gaps in understanding between practicing physicians (curative medicine) and those trained in public health and epidemiology (population medicine). In the last century, these groups were closer, as physicians played a role in public health, sanitation and in the prevention of the spreading of infection. However, with the recent extraordinary successes of the biomedical model in explaining disease, and the ensuing explosion of remarkable - and expensive - medical procedures and treatments, public health, preventive medicine and the population approach in general have been overshadowed. In this essay, I try to explain how the training of physicians and the daily care of patients may hinder their appreciation of the population model. For instance, for many of the myriad decisions involved in patient care in daily practice, there is little evidence, population derived or otherwise. What little evidence there is may be dominated by personal experiences, opinions and values. Additionally, the statistical and epidemiologic approach necessary for the maintenance of health and prevention of illness may not be valued by practitioners whose training and focus is on treating sick people one by one. To illustrate these disparities in understanding, examples are given from the NIH Consensus Conference on mammography screening for women aged 40-49, and from the use of science in the courtroom in adjudicating toxic tort cases. Understanding population medicine requires an appreciation of the concepts of chance, probability and statistics and of epidemiologic principles, difficult areas for many - including the general public. These topics play a small to nonexistent role in the formal training of most physicians. Some closing of the gap in understanding may be occurring. It is hoped this essay will help.