Teaching and learning quaternary prevention

This article presents an overview of different techniques and skills necessary for teaching and learning quaternary prevention (P4). It adopts the Expertise Model that defines the competences required in P4 for each level: novice, competent, proficient, and expert. This framework should be used as a step-wise roadmap for teachers in order to achieve high levels of performance. This proposal is complemented by a list of methods applied in teaching and assessment of learners’ performance and competence. By covering a range of learning and teaching issues, those who aim to teach quaternary prevention can explore the proposed framework. Quaternary prevention is a research and teaching fertile medical field that entails the integration of different areas such as health service organization, epidemiology, communication skills, and andragogy either at the macro or the micro levels of health related activities.

"One of the first duties of the physician is to educate the masses not to take medicine"Sir William Osler (p.105) 1

Introduction
Quaternary Prevention (P4) is defined as "the action taken to identify a patient or a population at risk of overmedicalization, to protect them from invasive medical interventions and provide for them care procedures which are both scientifically and ethically acceptable". 2,3It is considered by many a controversial concept, mainly because it follows a different direction from the other prevention concepts (primary, secondary and tertiary prevention) which lead to more interventions. 4e concept of P4 is better integrated by generalists as general practitioners/family physicians (GP/FP) and practice nurses -because these specialists are not committed with specific parts of the body or groups of diseases. 5Medicine and its interventions are usually driven towards increasing both quality and expectancy of life; but, when in excess, even apparently simple interventions as screening procedures may have opposite effects. 6The impact of unwanted effects from excess of medical interventions only recently (a few decades ago) became an object of epidemiological studies. 7serving the way "market driven influences" favour and induce overdiagnosis, overscreening, incidentalomas, overtreatment and overmedicalisation, it is necessary to remind all medical professionals of the first basic principle of our activity: primum non nocere. 8,9Disease mongering, disease marketing and branding of conditions are the weapons handled by the bigpharmas, supported by their effective partners in medical associations and classification boards. 10Instrumental to this is the widespread use of fake publications with the benediction of some medical press and academic centres in a broad picture of institutional corruption and the complicity of public health policies which have long ago forgotten their responsibilities towards the people they should serve. 11,12To contradict this status quo, and to help doctors to be in the best conditions to understand and avoid these "market driven influences", therefore acting in the best interest of their patients and society as a whole, we need to bring up a wide programme of learning and teaching P4.

The learning/teaching process
Quaternary Prevention is a decisive and sensitive concept.It should be learned and taught bearing in mind that together with its strengths there are also threats.The main threat is to transform the research in this field in a ghetto or to reduce it into a kind of political militancy.Since health services have undergone a huge transformation, becoming more like an industry, one of the main values of medicine -"primum non nocere" -has become a sort of "different" and "strange" concept, almost an "aberration". 13Teachers in the quaternary prevention field should take these issues into consideration.

The learners
Any learning/teaching process must define the target group. 14This paper is intended to address the medical students and doctors, at all levels of medical learning process: (1) undergraduate medical programmes such as Basic Medical Education-BME which focus on students; (2) Specialty Training programmes with a focus on GP trainers and GP trainees (ST); and (3) Continuing Medical Education (CME)/Continuing Professional Development (CPD), aiming the health professionals.

The teachers
Over recent years a greater proportion of the teaching at undergraduate level (BME) is being provided by general practice based teachers coming from a practice setting. 15The same happens with trainers involved in ST, and CME/CPD Tutors.The teaching of P4 requires special knowledge and skills, as well as a close working relationship between teachers and learners.The main competences for a teacher of quaternary prevention addressed in this article are presented below.

Communication skills with the patient
Patients learn since childhood "what is the purpose of a doctor": to complain about pain and other physical symptoms, to talk about diseases or health problems, or, in a relatively recent scenario, to ask for medication, screenings or other procedures.When this process happens and patients learn how to communicate with doctors only about their disease this can produce a behavioural pattern or even a vicious cycle (Figure 1).It is often a skilled doctor who usually breaks this behavioural pattern and explores with the patients about their fears or expectations.Many symptoms such as agitation, thoracic pain, or depression often reflect underlying personal issues, which are not easy for patients to express them.Additionally, the media reinforces this disease behavioural and communication pattern by "selling" the idea that doctors save lives and deal only with diseases and physical symptoms. 16Hence, one of the most crucial tasks for health professionals is to detect when a given intervention is not appropriate for an individual patient.A decoding process becomes necessary in order to deeply access and understand patients' feelings, fears, ideas and expectations, as well as associated signs and symptoms, considering patients' wider context. 17,18mmunication skills with the learners Teachers should understand how teachers teach and how adults learn.In teaching P4 we are dealing with adult learners (andragogy). 19Learning processes should be based in a relevant environment, actively involving teachers and learners at all stages in order to produce a reflective self-educating practitioner.Adult learning process works better when self-directed, experiential, need-based and problem-based directed.P4 teachers should use learner centred models of teaching to improve the communication with learners. 16

Personal attributes
Teachers should have open minds, good health, and master listening and communication skills.Additionally, they should be keen to share competencies and be skilful in organising their teaching activities.

Medical competences
Teachers should also be experienced as medical doctors and master up-to-date clinical knowledge and skills in order to teach P4.They should always aspire to an outstanding professional attitude and work in typical practice profile, as well as be involved in quality of care improvement and keep appropriate records.Finally, teachers should have a firm commitment to teach P4 at all levels.

The working environment
Teaching quaternary prevention can be more of a challenge when the health systems are not rational and well-organised.Rational health systems rely on strong primary health care and skilled generalists working in teams and in a network environment.Additionally, for learners, it might sound contradictory and confusing to practice and learn quaternary prevention in an 'ill-organised' health system, such as systems without a clear regulation, lacking lists of patients per general practitioners (i.e.family doctors being the gatekeepers of hierarchical health systems) and being driven by market.In order to overcome the difficult task of teaching P4, teachers might choose or develop their own strategies, based upon different teaching and learning styles.Hence, quaternary prevention can be practiced and taught at individual level but attains maximum effectivity when aimed towards the population as a whole, which requires a "task force" effort. 20e objectives: what we are going to teach?
To organise the different and complex competences needed to perform quaternary prevention, and the steps for mastering those competences through the learning/teaching process, we decided to apply the Expertise Model: the Dreyfus brothers 4-stage model, defining the characteristics of functioning at each level: Novice, Competent, Proficient, and Expert. 21his model was successfully used as "Framework for Continuing Educational Development of Trainers in General Practice/Family Medicine in Europe" by the European Academy of Teachers in General Practice/Family Medicine (EURACT) and partners (College of Family Physicians in Poland; Health and Management Ltd.; ZiZ Education Centre Ltd.; Danish College of General Practitioners; Institute for Development of Family Medicine; Greek Association of General Practitioners; Portuguese Association of General Practitioners; and Turkish Association of Family Physicians). 22The objectives of the learning/teaching process are (among others possible) described in Table 1.
Table 1.Domains of Teaching Quaternary Prevention. 21        The methods: how we are going to teach?

Domain
All teaching methods (Table 2), from traditional lectures to direct observation, can be useful, depending on the learners' stage and on the aims of the teaching session.Therefore, as learners progress in their learning journey towards expertise in quaternary prevention (as in other medical subjects), the teaching methods used can vary.They can be categorized by context: large/small groups; one-to-one; and self-directed study.

Assessment and evaluation: how we will know that learning took place?
There is a range of assessment methods which can be used to evaluate the acquisition of competences in the area of quaternary prevention, and/or to gauge if learning/teaching process has really occurred.The long list could include:    Performance assessment should be embedded in the curriculum (for students or trainees) or in daily practice (for licensed doctors).Such programmes of assessment cannot be improvised and should be planned, prepared, implemented, evaluated and improved. 23When assessing the performance of quaternary prevention activities, appraisers are mostly dealing with workplace-based assessment.Therefore, it is advised to use the following methods as they are more effective (Table 3). 24

The learning journey
In order to easily demonstrate the progressive journey towards expertise in quaternary prevention, Figure 2 shows the Dreyfus model of skills acquisition which has a remarkable illustrative capability. 23The progression from novice to expert through the stages of competent and proficient usually happens in parallel with the evolution inside the profession from the medical student to the experienced doctor.
Even if there is not a biunivocal relation between medical student and experienced doctor, it is expectable to find proficiency and expertise more widely expanded in the latter.In fact, students deal mostly with knowledge and its application (KNOWS and KNOWS HOW, in Miller's Pyramid); trainees apply their multiple skills -communication, problem-solving, management -in a (more or less) protected environment (SHOWS); and full trained doctors (young or experienced doctors) fully exert their professional performance (DOES), hence, being able to bring quaternary prevention into the real world of their patients. 24

Conclusion
The learning/teaching journey in quaternary prevention involves many skills.It is a complex field where epidemiology, communication, doctor-patient relationship, learning-centred approach, along with many others abilities are important topics that must be present in a balanced way.There are, however, 'risks along the road', the main one is the transformation of quaternary prevention in a simple political issue, instead of placing it as a practical and research medical field, which requires to be taught and learned.
Medical students often see "biological science" as separated from political or economic issues. 11The challenges of teaching quaternary prevention should not only integrate the "bio-psychosocial" or the holistic approach, but should also seek to integrate the macro and micro views of different areas such as economy, health services organisation and technological incorporation policies.The educational process within the field of quaternary prevention requires high level of teaching skills, mainly focused on andragogy.Efforts to enlighten the lay public on P4 subjects are extremely important and the trend is that, sooner or later, this issue will need to be addressed.The same need also applies to health professionals other than doctors.

Figure 1 .
Figure 1.Vicious cycle identified in doctor-patient communication.Source: elaborated by the authors.
Capability of self-assessment.Self-awareness of own emotional responses in dealing with P4 issues.Use self-knowledge as a tool in relating to patients and team when dealing with complex situations.Influence others into self-knowledge, providing adequate methods when needed and establishing the reports with P4.Source: elaborated by the authors from the professional standards for conservation, Institute of Conservation, London, 2008, based on the Dreyfus model of skill acquisition.21 trainers and trainees (or other learners).Source: elaborated by the authors from the professional standards for conservation, Institute of Conservation, London, 2008, based on the Dreyfus model of skill acquisition.21

Familiar
by the authors from the professional standards for conservation, Institute of Conservation, London, 2008, based on the Dreyfus model of skill acquisitionKnow NNT and NNH.On their therapeutic activities always take into account NNT and NNH, and discuss it with their patients.Have broad access to NNT and NNH discussions, include them in all activities and medical reasoning, and influence others with groups of patients and the communities in these matters.Source: elaborated by the authors from the professional standards for conservation, Institute of Conservation, London, 2008, based on the Dreyfus model of skill acquisition.21

Facilitate
by the authors from the professional standards for conservation, Institute of Conservation, London, 2008, based on the Dreyfus model of skill acquisition.21

Familiar
the fight against diseasemongering.Source: elaborated by the authors from the professional standards for conservation, Institute of Conservation, London, 2008, based on the Dreyfus model of skill acquisition.21

Table 1 .
21ntinued... by the authors from the professional standards for conservation, Institute of Conservation, London, 2008, based on the Dreyfus model of skill acquisition.21

Table 1 .
21ntinued... : elaborated by the authors from the professional standards for conservation, Institute of Conservation, London, 2008, based on the Dreyfus model of skill acquisition.21 Source

Table 3 .
25erview of methods used to assess medical competence at the "does" level.25 Source: based on EURACT Performance Agenda of General Practice/Family Medicine.Stefan Wilm, Ed.Düsseldorf University Press, Düsseldorf, 2014.