The words of prevention , part II : ten terms in the realm of quaternary prevention

Objective: this part II article about the ‘words of prevention’ presents in a terminological way the content of ten current concepts used in the prevention domain which are closely linked to quaternary prevention: (1) overinformation; (2) overdiagnosis; (3) medically unexplained symptoms; (4) overmedicalization; (5) incidentaloma; (6) overscreening; (7) overtreatment; (8) shared decision making; (9) deprescribing; and (10) disease mongering. Methods: with the support of the laboratory team of the University of Rouen, France, which is dedicated to medical terminology and semantic relationships, it was possible to utilize a graphic user interface (called DBGUI) allowing the construction of links for each of chosen terms, and making automatic links to MeSH, if any. Those concepts are analyzed in their environment in current literature, as well as in their MeSH counterparts, if any, and related semantic online terminologies. Results and Discussion: the rules in terminological development aspire to cover the whole field of a concept and in the meantime, they can help to avoid the noise due to proxy and not exactly related issues. This refers to exhaustivity and specificity in information retrieval. Our finds show that referring to MeSH only in information retrieval in General Practice/Family medicine can induce much noise and poor adequacy to the subject investigated. Conclusion: gathering concepts in specially prepared terminologies for further development of ontologies is a necessity to enter in the semantic web area and the era of disseminated data in family medicine. Resumo Objetivo: este artigo parte II sobre as ‘palavras da prevenção’ apresenta de uma forma terminológica o conteúdo de dez conceitos atuais utilizados no domínio da prevenção, que estão intimamente ligados à prevenção quaternária: (1) sobrecarga de informação; (2) sobrediagnóstico; (3) sintomas sem explicação médica; (4) sobremedicalização; (5) incidentaloma; (6) sobrerrastreamento; (7) sobretratamento; (8) tomada de decisão compartilhada; (9) desprescrição; e (10) comercialização de doenças. Métodos: com o apoio da equipe do laboratório da Universidade de Rouen, França, que se dedica à terminologia médica e às relações semânticas, foi possível utilizar uma interface gráfica de usuário (chamado DBGUI) permitindo a construção de links para cada um dos termos escolhidos, fazendo ligações automáticas para o MeSH, caso houvesse. Estes conceitos foram analisados no seu ambiente na literatura corrente, bem como os seus homólogos no MeSH, caso houvesse, e terminologias semânticas online a eles relacionadas. Resultados e Discussão: as regras em desenvolvimento terminológico aspiram cobrir todo o campo de um conceito, ao mesmo tempo em que podem auxiliar a evitar ruídos devido a aproximações e questões não exatamente relacionadas. Isto se refere à exaustividade e especificidade na recuperação da informação. Nossos achados mostram que referir-se somente ao MeSH na recuperação de informação em medicina de família pode induzir muito ruídos e uma pobre adequação em relação ao tema investigado. Conclusão: reunir conceitos em terminologias especialmente preparadas para um maior desenvolvimento de ontologias é uma necessidade para se adentrar na área da rede semântica e da era de dados disseminados em medicina de família. Cite as: Jamoulle M, Gavilán E, Cardoso RV, Mariño MA, Pizzanelli M, Grosjean J et al. The words of prevention, part II: ten terms in the realm of quaternary prevention. Rev Bras Med Fam Comunidade. 2015;10(35):1-11. Available at: http://dx.doi.org/10.5712/rbmfc10(35)1063


INTRODUCTION
There are striking differences in the world of reference 1,2 of General Practice/Family Medicine comparing to those of academic and other specialized branches of medicine. These differences started to be addressed in the part I of this paper. The part I article identified some of the main words of prevention, representing the P4 paradigmatic shift from a chronological based prevention towards a constructivist view based on patient-doctor relationships. It also discussed words such as clinical prevention, primary prevention, secondary prevention, tertiary prevention, and quaternary prevention.
This part II article discusses other P4 related concepts such as overinformation, overdiagnosis, medically unexplained symptoms, overmedicalisation, incidentaloma, overscreening, overtreatment, shared decision making, deprescribing and disease mongering. Since family doctors do not use the same wording as patients, librarians or focal medical specialists (consultants) there is a need for disambiguation of meanings. The latter rules health information retrieval and consequently high-precision information retrieval tools are needed. 3 Jamoulle M, Gavilán-Moral E, Cardoso RV, Marino MA, Pizzanelli Báez M, Grosjean J, Darmoni S. The words of prevention . Part II. New terms in the realm of Quaternary prevention. Rev Bras Med Família e Comunidade. 2015; accepted.

5
As a by-product of the doctor-patient relationships, quaternary prevention encompasses concepts that each of them deals with ethical issues in day to day medicine. These concepts are the focus this paper (see Table 1). The impact of computer science on terminological issues is striking and Family doctors have to understand that mastering the production and management of knowledge lies at their doorstep. They have to become familiar with semantic web technologies and related language processing as the computer will become omnipresent in their daily life in a near future. For a GP, understanding health information gateways is as important as to understand Evidence Based Medicine (EBM) or pharmacology. This paper highlights some basic steps necessary to master health information.

METHODS
The computer laboratory of the University of Rouen, France, dedicated to medical terminology and semantic relationships, maintain a 50 terminologies crossing website, linked by semantic web technologies under the URL of www.hetop.eu. 8 The proposed terms which content are historically marked. 9 An external observer, expert in the domain of Family Medicine, has to verify the proposed links.
Gomes et al have pointed, in this special issue on P4, the vicious cycle identified in doctorpatient communication. The link between lay and professional term is essential to enhance communication in primary care. This is the reason for the links of the DBGUI was completed with chosen links to Babelnet.org 10 and to Dbpedia, 11,12 one of the main nodes of the Linked data world 13 and consequently with Wikipedia. 14 Gathering concepts in specially prepared terminologies for further development of ontologies is a necessity to enter in the semantic web area and the era of distributed data. 15 The present results open the way to build a comprehensive set of main themes addressed by GPs during some conferences. 16

RESULTS
The ten terms are presented here in four languages with the links, definition(s) and their source(s) and bibliographic citation(s). The Table 2

Spanish PT incidentaloma
Portuguese PT incidentaloma Definition Incidentaloma: used to design an incidentally discovered mass, by chance, in an asymptomatic person, which probably never will harm his/her, not excluding a real possibility of damage and a few chance of benefit. It is a form of overdiagnosis emerging from the massive use of high-resolution diagnostic imaging. In many cases, it is associated with the increased rate of new diagnoses, causes anxiety, consumes time and resources, and can even induce damage by the subsequent follow-up. ( Babelnet bn:02354871n Disease mongering is a pejorative term for the practice of widening the diagnostic boundaries of illnesses, and promoting public awareness of such, in order to expand the markets for those who sell and deliver treatments, which may include pharmaceutical companies, physicians, and other professional or consumer organizations.

DISCUSSION
Out of an ongoing research on the conceptual content of General Practice/Family medicine, 10 terms used by GPs in their communications to congresses have been analyzed in a terminological way with the help of a web based terminological graphic user interface.
The particularity of the selected terms relates to the dangers of medicine and ethical duties of family doctors facing the epidemic of overmedicalization. Each of those ten terms is carefully related to the fourth field of prevention described in this special issue on P4.
Family doctors have to understand the basis and principles of overmedicalization, which encompass overinformation, overscreening, overdiagnosis, incidentaloma, disease mongering, and overtreatment. Each of those moves could imply the surge of possible Medically Unexplained Symptoms. Shared decision making is one of the suggested tools to address the discrepancy between the doctor and the patient, in the chaos described by Stacey, when disagreement meets uncertainty. 21 Deprescription, more frequently referred to deprescribing, is another way to introduce quality assurance and control in the therapeutic process. In this sense, all the means dedicated to establish quaternary prevention are powerful tools to avoid the chaos and the terrible waste of resources either of human or economic, leading to a more sustainable health care by 'effectively implementing and maintaining of evidence-based policies and activities'. 22 The rules in terminological development aspire to cover the whole field of a concept and in the meantime, it helps to avoid the noise due to proxy and not exactly related issues. This refers to exhaustivity and specificity in information retrieval. "A great difficulty is that we cannot read the user's mind to acquire what he/she really wants". 23   Overmedicalization poses different issues as we could use Conrad's definition and adding the qualifier 'ethics' to find back the ongoing meaning of the word overmedicalization which count in Medline varies following its orthographic typing, the European way overmedicalisation with 'S' reflecting more the quaternary prevention mode of the phenomenon. It is important to highlight that overmedicalization and overtreatment refer both to unnecessary health care. This broad category is coming through Babelnet quotations from Wikipedia categorization process. Indeed, the choice of Wikipedia has been to class all the above analyzed terms in the broad category of unnecessary health care. 25 Interestingly, all the ten terms are shared by lay terms terminologies as Babelnet of DBpedia, reflecting the interest of patients and general public for those problems, which are clearly at the meeting point of medicine with the public.
Naturally, all those terms reflecting overutilization and waste of resources have to be complemented by the careful analysis of their counterparts: undermedicalization, undertreatment, underscreening. These are the natural companion of the analyzed terms.
But, unfortunately, market driven forces are prevalent, and consequently, the trend is in the direction of overmedicalization or wrong medicalization, which occurs in low-income countries, as well.

CONCLUSION
One can argue that the definitions proposed here are up to only one author and that careful search in published literature could retrieve more appropriate citations. Nevertheless, a lot of colleagues, acknowledged above, have contributed to this work, by spontaneous exchanges through the P4 mailing lists 26 between Europe and mainly South America. This is an open field of research and this paper is only a provocative appeal to invest more in specific terminological work dedicated to family medicine and primary care. Terminologies are evolutionary by essence and require to be adjusted to the need of corresponding domains of