Quaternary prevention: first, do not harm

Marc Jamoulle


Towards patient-doctor relationship based care

Clinical prevention, under the influence of public health, has been organised in a chronological
manner since the middle of the 20th century. A paradigm shift from a chronological to a constructivist
relationship-based preventive pattern of care1 offers new insights into the practice of doctors.
This paradigm shift brings to light the concept of quaternary prevention, a critical look at medical
activities with an emphasis on the need not to harm. Quaternary prevention addresses the fundamental
question of what constitutes too much or too little medicine. It is the fourth form of disease prevention,
but also the fourth frame of action for family doctors (Figure 1).
The shift from time-based prevention towards a relationship-based organisation offers new
perspectives into physicians’ work. The physicians observe themselves and question the ethical limits
of their activities. In this sense, quaternary prevention is aimed more at the doctor than the patient.
Moreover, the four definitions of prevention, published in the Wonca Dictionary of Family Medicine,2
offer a structured way to discuss the activities of family doctors, including ethical considerations on
the patient-doctor encounter. Quaternary prevention, also known as P4, is a new term for an old
concept: first, do not harm. This concept enforces disciplines and attitudes such as evidence-based
medicine, quality assurance, defensive medicine, avoiding abusive nosographic diagnoses and ethical
issues including those linked to overinformation, and overmedicalisation.3



Quaternary Prevention; Physician-Patient Relations; Medicalization; Primary Health Care; Family Practice.

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Jamoulle M, Tsoi G, Heath I, Mangin D, Pezeshki M, Pizzanelli Báez M. Quaternary prevention, addressing the limits of medical practice. Wonca world conference Prague 2013 Retrieved from http://www.ph3c.org/PH3C/docs/27/000322/0000469.pdf

Jamoulle M, & Roland M. Quaternary prevention. From Wonca world Hong Kong 1995 to Wonca world Prague 2013. In Wonca world conference Prague 2013 (Poster). Retrieved from http://www.ph3c.org/PH3C/docs/27/000284/0000435.pdf

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Silva AL, Mangin D, Pizzanelli M, Jamoulle M, Wagner HL, Silva DH et al. Manifesto de Curitiba: pela Prevenção Quaternária e por uma Medicina sem conflitos de interesse. Rev Bras Med Fam Comunidade. 2014;9(33):371-374. Disponível em http://dx.doi.org/10.5712/ rbmfc9(32)1006.

DOI: https://doi.org/10.5712/rbmfc10(35)1064


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