Public health vs. clinical medicine

It’s a typical mid-summer day in Richmond—really hot and very humid. It’s my favorite time of the year (I must have been a plant in a previous life!). So I went to soak up the weather by washing my car. This is a mindless activity that I enjoy because it gives me time to think. I began to think some more about the issue of giving camp kids Tamiflu that I blogged about this morning. It’s a good example of the tension that exists between public health and clinical medicine. As an epidemiologist and a clinician, I can appreciate both arguments. But I have often found myself at odds with public health practitioners over issues like post-exposure prophylaxis. It seems to me that a lot of people in public health have a purist approach and a willingness to play the odds with risk that makes the clinician uncomfortable. Moreover, there’s a detachment that those of us who see patients can’t accept. Don’t get me wrong—I have great admiration for public health practitioners and the important work they do for little money or recognition.

As an example, following a case of meningococcal meningitis, my approach to who should receive postexposure prophylaxis is typically more lenient than my public health colleagues. Given the severity of the disease, the ease of giving a single dose of ciprofloxacin, and the comfort this provides to the contact and family members (a placebo effect of sorts), it doesn’t seem appropriate to me to make a big production of “the rules” about who should receive prophylaxis, especially since the rules are relatively arbitrary anyway. A death from an infectious disease may be viewed as a case by the public health community. To the clinician, it’s a patient—someone’s child, mother, father, brother or sister. A few years ago, I attended a conference about a rabies case given by a public health colleague. It was technically an excellent presentation, but what I remember most was how proud she was about how few doses of rabies prophylaxis were given to contacts of the case. All I could think about was how would she have felt if one of those contacts developed rabies? In the New York Times article from this morning we see the tension between Dr. Marc Siegel (the parent and clinician) and Dr. Anne Schuchat (the public health official), who seems to be applying the rigid rules in a not too empathic way. Maybe public health doctors should spend some time in the clinical setting to be reminded that behind every case of a reportable disease is a real human being and that decisions at the bedside are rarely so black and white.


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