A proposal to incorporate a public health perspective into clinical teaching.

BACKGROUND: In medicine today the 'whole person with an illness' struggles for attention in a health system dominated by a specific focus on disease. A reductionist approach alone is inadequate. CONTEXT: Efforts to broaden the medical curriculum through integrating public health into clinical practice have been numerous, yet the clinical application of a broad public health perspective in medical education has been frustrated by a number of factors. INNOVATION: This paper is a proposal to incorporate a public health perspective into clinical decision making, in order to assist the student to develop a comprehensive approach to clinical assessment. The proposed framework formalises the assessment of the patient's personal and social context, which is used to complement disease assessment and diagnosis. My suggestion is to use the SOAP format (subjective, objective, assessment and plan) as the framework for clinically processing a public health perspective of the patient. I have classified the public health perspective in terms of seven categories of the patient's context (cultural, social context, psychological context, population health context, social determinants, health services context and the information context). Within each of these categories the student clinician gathers subjective and objective public health data, which is used in combination with diagnostic clinical data to formulate the whole-patient assessment and plan. IMPLICATIONS: The next step is to trial and evaluate the effectiveness of the proposal in promoting the assessment of the whole person with an illness.

Symptoms of impairment, disability and handicap in low back pain: a taxonomy.

The functional consequences on everyday living which result from chronic low back pain commonly require services which are difficult to access. This deficiency in meeting the needs of these patients is partially explained by inadequacies in clinical assessment. Medical evaluation may be exhaustive, but frequently the assessment of physical and psycho-social dysfunction at the personal and family level is inadequate. In low back pain, as with most chronic ailments, there is no agreed-upon taxonomy of the functional consequences of the disorder upon which to establish a comprehensive clinical appraisal. In this paper a taxonomy is presented for the impairments, disabilities and handicaps which result from chronic low back pain. The taxonomy has been based on data from a survey of 74 individuals with low back pain and is structured generally according to the International Classification of Impairments, Disabilities and Handicaps (WHO 1980). The taxonomy is proposed as a conceptual framework and vocabulary for both clinical practice and research. The taxonomy is not a measurement instrument nor does it indicate the frequency of occurrence of disabilities. A classification is basic to the advancement of scientific understanding, and usage of a standard vocabulary such as this plays an important role in establishing a responsive health service capable of meeting the needs of the population with chronic low back pain.