Domhnall MacAuley: 11th Brazilian congress of family and community medicine

Domhnall MacauleyQuaternary prevention – ever heard of it? We know about primary, secondary, and tertiary prevention, but this is different. It means protecting healthy patients from unnecessary investigations, tests, or treatments. Marc Jamoulle (Belgium) introduced the concept in1995 but it gained traction mostly in non English speaking countries. Patients without recognised illnesses are increasingly vulnerable through our emphasis on screening, early detection, and the technological innovations in diagnosis. Quaternary prevention means protecting patients from medical interference – a role where general practice is pivotal. Interestingly, he told me this idea first came to him while doodling with two by two tables at an epidemiology lecture. Serendipitous.

Marcello Garcia Kolling (Brazil) held his audience of more than 700 delegates enthralled. This guy knows how to communicate and even I, with minimal Portuguese, was fully engaged with his presentation. His topic was management of urinary tract infection in women – and he certainly made it come alive,  not least when describing the practical difficulties for women in providing a mid stream urine sample. His two main messages were about treating empirically before awaiting a culture result and the accuracy of clinical prediction rules. For an audience used to didactic secondary care teaching, this was radical. But, his audience were most surprised when told that Quinolones were not the treatment of choice. The only downside, Marcello told me afterwards, was that almost all his evidence was from European research. He couldn’t find any from Brazil.

Have you ever been scheduled to give a 3 hour lecture? Would you like to give it on medically unexplained symptoms.  It didn’t seem to bother Iona Heath (UK) who split the session into a talk and an audience discussion section followed by questions and answers.  Not easy to do this with simultaneous translation. And this wasn’t simply a question and answer session, it was a true dialogue – a conversation with the audience – and a feature of many of the sessions at this conference. As I watched Iona, I was taken by the background quotation on screen that said “Instead of just declaring a condition as unexplained, the doctor might consider on what level of understanding the illness becomes explained”

I met a legend. Not a high profile celebrity but a quiet modest woman who has achieved more than most of us could imagine. Dr Monique, a family doctor and a nun, came to SaoPaulo from Quebec 16 years previously and now runs a huge NGO – Santa Marcelina- that cares for a vast population in the east side of the city. Community health care is contracted to 12 NGOs and Santa Marcelina has its roots in the poorest community. She runs a major teaching hospital, a network of health care units, and a primary care training scheme. Creating a research culture and community is her next challenge. And, she will succeed.

“What did I think of the meeting – how did it compare with the many other primary care meetings I attend?” asked Judy Belle Brown (Canada). I replied that I had never seen anything quite like it. There were 4000 delegates with few over forty years of age. Up to 18 parallel sessions that all seemed to come together effortlessly, and there was no pharmaceutical involvement. An incredibly young and vibrant college. Such was the energy, enthusiasm, and optimism, it felt like a student jamboree. They could be the future leaders in primary care research. But, I don’t think they quite appreciate their own potential.

Domhnall MacAuley is primary care editor, BMJ