First do not harm.

In their paper Bharti Kalra and Sonia Malik are addressing the issue of the transformation of menopause, a usual asymptomatic problem in a so-called treatable disease.[1]

They argue that menopause and androgenic natural deficiency have been “branded” by unscrupulous marketers. To highlight this unusual position, they are referring to the concept of quaternary prevention.

I would say I am grateful to those authors to refer to my work endorsed by the Wonca International Classification Committee (WICC) and I am pretty proud to contribute to the general reflection about the patient doctor relationship and its consequences for the organization of health care. I have been amazed to read, soon after, two other Indian publications dealing with quaternary prevention in anesthesiology and thyroidology.[23]

Quaternary prevention is born by introducing patient and doctor instead of a test in a chi square draw. It highlights four fields of the patient-doctor encounter based on relationships. The doctor looks for diseases. The patient could feel ill. Timeline is obliquely oriented from left to right, from alpha to omega, from birth to death. Anyone will become sick and die, doctors as well as patients. The fourth field influences the 3 others [Figure 1].[4]

Figure 1

Four fields of the patient-doctor encounter based on relationships. The doctor looks for diseases. The patient could feel ill. Timeline is obliquely oriented from left to right, from alpha to omega, from birth to death. Anyone will become sick and die, doctors as well as patients. The fourth field influences the 3 others (Jamoulle 1986)

This represents a paradigmatic shift from a chronological to a constructivist relationship-based preventive pattern of care and offers new insight into the practice of doctors and a critical look at medical activities with an emphasis on the need not to harm, perfectly in line with the current discussion about overmedicalization. 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 doctors.

The four definitions of prevention published in the Wonca Dictionary of Family Medicine[5] 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 a heartsink patient.

The P4 network has now members worldwide expressing through websites, Facebook and Twitter. P4 is now widely accepted by Wonca and a poster has been translated in French, Spanish, Portuguese, Vietnamese, Thai and Chinese.[6] For information about quaternary prevention-related events, links, bibliography and slides, have a look at the Quaternary Prevention rubric of WICC website (www.ph3c.org/p4)