Summary

Public health efforts have resulted in tremendous improvements in the health of individuals and communities. Vaccines, improved sanitation and hygiene, safer workplaces, enhanced food and drug safety, and preventive health services aimed at such things as alcohol and drug use have all led to improvements in the health and well-being of people of all ages and backgrounds. Public health, an interdisciplinary field of study and practice devoted to preventing illness, disease, and injury and to promoting and protecting human health with respect for human rights and dignity, is defined as “what we as a society do collectively to assure the conditions in which people can be healthy” (IOM, 1988). The foundation for effective public health interventions rests on sound scientific principles, strong organizations committed to improving the health of the public, and a well-trained workforce of sufficient numbers and diverse disciplines to address current and emerging public health needs. Unfortunately, despite the achievements of public health, there is now a growing shortage of public health workers (ASTHO, 2004), including a critical shortage of public health physicians, and many who are currently employed in public health are unevenly prepared to face today’s public health challenges (Kennedy et al., 1999; Glass, 2000; Turnock, 2004).

Concerned about a lack of well-trained public health physicians, the U.S. Congress mandated that the Institute of Medicine (IOM) undertake a study to determine (1) what knowledge and skills are needed by public health physicians, (2) the number of programs needed to maintain an adequate supply of physicians trained for public health careers, and (3) how



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Training Physicians For Public Health Careers Summary Public health efforts have resulted in tremendous improvements in the health of individuals and communities. Vaccines, improved sanitation and hygiene, safer workplaces, enhanced food and drug safety, and preventive health services aimed at such things as alcohol and drug use have all led to improvements in the health and well-being of people of all ages and backgrounds. Public health, an interdisciplinary field of study and practice devoted to preventing illness, disease, and injury and to promoting and protecting human health with respect for human rights and dignity, is defined as “what we as a society do collectively to assure the conditions in which people can be healthy” (IOM, 1988). The foundation for effective public health interventions rests on sound scientific principles, strong organizations committed to improving the health of the public, and a well-trained workforce of sufficient numbers and diverse disciplines to address current and emerging public health needs. Unfortunately, despite the achievements of public health, there is now a growing shortage of public health workers (ASTHO, 2004), including a critical shortage of public health physicians, and many who are currently employed in public health are unevenly prepared to face today’s public health challenges (Kennedy et al., 1999; Glass, 2000; Turnock, 2004). Concerned about a lack of well-trained public health physicians, the U.S. Congress mandated that the Institute of Medicine (IOM) undertake a study to determine (1) what knowledge and skills are needed by public health physicians, (2) the number of programs needed to maintain an adequate supply of physicians trained for public health careers, and (3) how

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Training Physicians For Public Health Careers these programs can be funded (Consolidated Appropriations Act, 2005, Public Law 108-447, Conference Report 108-792). This report is the result of the deliberations of the committee assembled to address that charge. A critical task for the committee was the development of a vision of the future public health physician workforce to guide the committee’s work. The committee’s vision has three components. First, the committee envisions a future in which sufficient numbers of well-trained public health physicians work with other public health professionals to address population issues such as health promotion and disease prevention, chronic and infectious diseases, safe food and water supplies, sanitation, and environmental exposures. Second, the committee envisions a future in which sufficient numbers of well-trained public health physicians are available to provide the scientific and clinical input along with the leadership and management necessary to link and coordinate the efforts of the many participants of a strong public health system. Third, in the face of public health emergencies, the committee envisions a future in which there will be sufficient numbers of well-trained public health professionals, including physicians, to plan for and prevent these emergencies or to respond to them. Such emergencies would include disasters such as hurricanes, bioterrorism, and emerging or reemerging infections such as pandemic influenza or multiple-antibiotic-resistant tuberculosis. Who are public health physicians? The committee has adopted the following definition: public health physicians are physicians “whose training, practice and world view are based in large part on a population focus rather than individual practice, that is, on assuring the availability of essential public health services to a population using skills such as leadership, management, and education as well as clinical interventions” (Gebbie and Hwang, 1998). WHAT SHOULD PUBLIC HEALTH PHYSICIANS KNOW? The health challenges of the 21st century (e.g., the increasing burden of chronic diseases, persistent and emerging infectious diseases, and disaster response) require the medical and public health communities to work in concert. Additionally, given the increased understanding of the multiple determinants of health, physicians must be aware of not only the biological risk factors but also the behavioral and environmental factors that can affect health in order to tailor interventions for individual treatment. Training physicians in population-based medicine as well as clinical medicine holds strong promise for augmenting the quality and effectiveness of clinical practice. However, the integration of these population health content areas into an already crowded medical school curriculum necessitates the development of creative approaches to curriculum

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Training Physicians For Public Health Careers development and teaching (e.g., case-based learning) as well as a cadre of faculty with the requisite knowledge. For the purposes of this report, the committee has identified three levels of physician engagement with public health. First, all physicians intersect with public health in many sectors of their practice and can be viewed as participating in public health activities, even though they are not defined as public health physicians. Second, there are physicians who practice public health for a portion of their career, full or part time, but primarily have a career trajectory in some other area of practice (e.g., a pediatrician working in school health). Finally, there are physicians with careers in public health, that is, physicians who can be identified as specializing in public health, whether they practice this specialty for an entire career or enter public health as a change in specialty at some point. These public health physicians work in a variety of settings; perform many different functions; and fulfill numerous roles, including policy development, leadership and management, programmatic expertise, and clinical services. The committee endorses the recommendation of the IOM report on educating public health professionals, Who Will Keep the Public Healthy? (IOM, 2003b), that all medical students receive basic education concerning the concept of determinants of health and an introduction to the content areas identified in that report (i.e., epidemiology, biostatistics, environmental health, health services administration, social and behavioral health sciences, informatics, genomics, communication, cultural competence, community-based participatory research, global health, policy and law, and public health ethics (IOM, 2003b)). Furthermore, the committee recommends that three additional areas be included in this basic education: leadership, clinical and community preventive services, and public health emergency preparedness; organizational partners (including but not limited to the Association of American Medical Colleges; the Association for Prevention, Teaching, and Research; the American College of Preventive Medicine; the American Association of Colleges of Osteopathic Medicine; the Association of Schools of Public Health; the Council of Accredited MPH Programs, and the American Association of Public Health Physicians) collaborate to develop models for integrating training in public health principles and practice into physician education at both the undergraduate and graduate levels; each graduate medical education program identify and include

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Training Physicians For Public Health Careers public health concepts and skills relevant to the practice of that specialty; and medical schools and graduate medical education programs include faculty with appropriate public health training and experience to teach public health content and serve as role models. Basic competency in population and public health is important not only for physicians currently enrolled in medical education programs but also for those already practicing medicine, regardless of their specialty. For example, all physicians require basic knowledge of epidemiological principles to interpret reports of new medical and behavioral approaches to disease management. Many currently practicing physicians, however, completed a medical education that had a less than complete basic public health content. Therefore, the committee recommends that physicians, most of whom have elements of public health in their practices, have access to a way to assess their public health competency and training needs as well as support for appropriate continuing education in public health. Medical specialty societies should provide this self-assessment and continuing medical education, including relevant emerging topics and public health practice updates. Periodic recertification examinations should include public health questions relevant to that specialty. Although an understanding of basic public health concepts is important for all physicians, a smaller number of physicians require a greater amount of knowledge of particular public health concepts and skills because a specific portion of their practice, practice setting, or practice role involves public health. Examples of physicians in this group include infectious disease physicians who investigate health care institution-associated disease outbreaks, pediatricians who work in school health, and emergency medicine specialists who direct emergency medical services. Additional training specific to the public health portion of practice is essential for these physicians. Therefore, the committee recommends that schools and programs of public health, state health departments, and specialty societies develop competency-based certificate programs and other training programs in public health that are based on the recommended 16 areas, consistent with principles of adult learning, and designed to enable physicians to obtain practice-specific public health training; and employers of physicians whose practice includes some component of public health support both initial and ongoing assessments of the training needs of these physicians, the preparation

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Training Physicians For Public Health Careers of personal development plans to address needed knowledge and skill areas, and funding to implement these plans. Physicians with careers in public health may practice public health for an entire career or may enter or leave public health as a change in specialty at some midpoint in their careers. Whether they practice public health full or part time, it is essential that their public health knowledge and practice meet the current standards for public health professionals as well as any standards relevant to their specific role in public health or to the populations that they serve. To ensure that these expectations are met, these career public health physicians require specific, enhanced public health training. Therefore, the committee recommends that physicians with careers in public health acquire a master of public health from schools or programs in public health or through preventive medicine programs; or a comparable degree or experience (e.g., through the federal or state Epidemic Intelligence Service programs). The training or experience should include the 13 content areas identified in the Institute of Medicine report on educating public health professionals (IOM, 2003b) plus the additional three content areas of leadership, clinical and community preventive services, and public health emergency preparedness recommended in this report. schools and programs of public health expand their recruitment of physicians into public health graduate programs in order to increase the number of physicians with public health training. Graduate programs should include a public health field experience. Revised accreditation criteria for schools and programs of public health establish 42 semester credit units as the standard length for an MPH degree. It is not known whether this increase in hours will make it more difficult for schools and programs of public health to recruit physicians into the MPH program. However, the accreditation criteria also provide for consideration of prior or concurrent academic studies or relevant work experience to be credited toward the degree requirements. It is to be hoped that other measures recommended in this report will help encourage physicians to complete an MPH. The committee believes it is important that, at a minimum, public health physicians understand the basics of each of the recommended content areas and the application of those basics to public health. It is important to emphasize that not all physicians with careers in public health are expected to become experts in each of the content areas identi-

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Training Physicians For Public Health Careers fied. Beyond that, the depth of knowledge and skill in the content areas will be determined by the public health role that each physician plays. WHAT IS AN ADEQUATE SUPPLY OF PUBLIC HEALTH PHYSICIANS? The second part of the committee charge, determining how many programs are needed to maintain an adequate supply of physicians trained in public health, presents two difficult questions. What is an “adequate” supply, and given the various ways in which public health physicians can be trained, how is it determined “how many training programs” are needed? To answer the supply question, one needs to know how many public health physicians currently exist, whether that number is adequate, and if that number is not adequate, what that number should be. Various attempts have been made to collect data on the number of public health physicians currently practicing in the United States by using available physician and public health databases and reports. Most of these reports have focused on governmental agencies. The reported numbers range from a low of 1,400 to a high of 22,000, but each of the methods used to determine these numbers is flawed in different ways. For example, some methods focus only on full-time equivalents in a particular kind of agency (e.g., a local health department); others collect data only on particular kinds of positions (e.g., the program manager), which makes it impossible to separate physicians from other types of professionals in those positions. Some collect data on the numbers of physicians employed but fail to identify whether their practice is in public health, whereas others ask physicians to self-identify as a public health physician but do not verify the type of practice. The lack of a consistent definition and inclusive approach to identifying and counting public health physicians makes it extremely difficult to determine accurately both the current pool of public health physicians, much less the desired number. This, in turn, impedes efforts aimed at planning for the number and kinds of training programs needed to prepare physicians for effective public health practice. Therefore, the committee recommends that the U.S. Congress designate funds for the Health Resources and Services Administration to conduct a periodic (every 3 to 5 years) comprehensive enumeration of the public health workforce, and filled and unfilled positions, with particular attention to physicians. The enumeration should include all civilian and military governmental agencies with public health responsibil-

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Training Physicians For Public Health Careers ities, public health academia, and significant voluntary agencies contributing to the public’s health. The enumeration should also include those physicians employed by private or public sector care delivery systems with public health responsibilities. the information regarding public health physicians obtained in the periodic assessment of the public health workforce be used to project needs for public health physicians and public health physician education programs, and to determine the level of funding necessary to prepare physicians to fulfill those needs. The public health system envisioned in the 2003 IOM report The Future of the Public’s Health (IOM, 2003a) includes governmental public health agencies at the core working with the health care delivery system, public health and health sciences academia, communities, business and employers, and the media. According to that report, governmental public health agencies form the backbone of the public health system and the actions that it takes. Without sufficient numbers of well-trained physicians in this backbone, the entire public health system is weakened. Both because of the importance and centrality of the “backbone” to assuring the public’s health and because available enumerations primarily focus on physicians in governmental agencies, the central focus of this report is physicians in governmental agencies. The tremendous differences in the data sources, time frames, and definitions used in these various reports prohibit any meaningful integration of the numbers; the easily developed challenges to any one of the methods used prohibits arbitrary use of any one of them. In determining the size of the current public health physician workforce, the committee relied most heavily on Enumeration 2000 and Bureau of Labor Statistics (BLS) data since they are most complete. These two most useful resources provide widely divergent numbers: Enumeration 2000, approximately 6,000; BLS, 22,000. Because the BLS data include physicians in other than public health positions and physicians with other than public health specialization, the committee determined this was an overestimate. However, the Enumeration most likely undercounted because categorization was by job title, and physicians are employed under titles such as commissioner, director, supervisor, epidemiologist, and surveyor as well as physician and public health physician. Taking into account the numbers and the sizes of agencies at all levels of government, the staffing patterns both reported and known to members of the committee, and indications from the agencies about the levels of vacancies, the committee’s considered opinion is that an estimate of 10,000 is reasonable, and could be used until such time as an improved data system is in place. If the estimated number of physicians currently employed in public

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Training Physicians For Public Health Careers health was reasonably accurate and reflected a fully met need and if these physicians followed a typical work career, it would be relatively simple to estimate the number of replacement physicians needed to be trained for public health careers over the coming decades. However, reports from public health agencies regarding the recruitment and the retention of staff indicate that there are serious gaps in the current supply of public health physicians. Furthermore, according to Glass (2000), there are decreasing numbers of physicians in public health and preventive medicine. The committee bases its estimate of need for public health physicians on the assumption that public health would best be served by physician participation in the public health leadership team, both at the agency level and in major programmatic areas. Although estimating the number of public health physicians in practice today, as well as extrapolating that number to meet future needs, is difficult, the committee used the available information to calculate what it believes to be the most reasonable estimate of need and arrived at the conclusion that 20,000 physicians are needed in public health careers, an increase of 10,000 over the current number engaged in public health careers. The committee is very aware that greater accuracy in estimating these numbers could be achieved if regular, comprehensive enumeration efforts were undertaken. It is also essential to plan for the replacement of physicians leaving the public health workforce for retirement or other reasons. If it is assumed that an average career path in public health is 15 years (on the basis of assumptions made about late entry into the field), approximately 1,3501 properly prepared public health physicians are needed every year to replace those leaving the existing workforce. Therefore, once the desired number of 20,000 public health physicians in governmental agencies is reached, the system must have the capacity to train at least 1,350 new physicians per year to replace those leaving public health careers. HOW MANY TRAINING PROGRAMS ARE NEEDED? Education in public health can be obtained in a variety of ways and at various points in one’s career, for example, through preventive medicine residencies, schools and programs of public health, the Epidemic Intelligence Service program of the Centers for Disease Control and Prevention, 1 This figure is derived by dividing the estimated number of physicians needed (20,000) by the estimated average length of career (15 years). The resulting number of 1,333 has been rounded to 1,350. The estimate of a 15-year career is based on the considered opinion of the committee since no data exist on this issue. In future, the numbers could be adjusted if data were collected and yielded a better number.

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Training Physicians For Public Health Careers certificate programs, public health training networks, and public health leadership networks. It should be noted, however, that these approaches do not provide a uniform set of knowledge about and skills in public health. Furthermore, evidence indicates that the current public health workforce is inadequately trained in many respects. It is important not only to look at training future public health physicians but also to ensure that those currently engaged in public health careers are adequately trained. Determining the training resource needs when neither the base population nor the turnover rate is accurately known is extremely difficult. Determining the training resource needs becomes even more difficult when the description of what constitutes a public health workplace or a medical practice contribution to public health is made more generous or is defined more broadly. As stated earlier, the current estimated number of physicians in governmental public health practice is 10,000, with an estimated need for 20,000 and an annual replacement need of 1,350. The committee focused particular attention on ensuring that sufficient numbers of governmental public health physicians are available and that the number of physicians pursuing careers in public health can supply this number on a routine basis. For this to happen, both the quality and the number of training programs for physicians must be increased. Therefore, the committee recommends that: The Centers for Disease Control and Prevention (CDC) expand the Epidemic Intelligence Service program to include double the current physician enrollment without diminishing the participation of other disciplines. CDC expand its Academic Health Department (AHD) program to sustain 30 AHDs. Requirements should include partnership with medical schools in order to encourage physician participation. State and large local health departments, in conjunction with medical schools and schools of public health, expand post-residency fellowships in public health that emphasize transition into governmental public health practice. Public health/general preventive medicine (PH/GPM) residency programs expand current capacity and add additional PH/GPM residencies as needed to graduate a minimum additional 400 residents per year. This expansion should be supported by federal graduate medical education funds that are not linked to provision of clinical medical services. The Residency Review Committee for preventive medicine review the content and quality of preventive medicine train-

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Training Physicians For Public Health Careers ing programs in the context of the recommendations in this and other recent IOM reports on public health to ensure that the training programs meet the needs of modern public health practice. Governmental public health agencies support both initial and ongoing assessment of the training needs of physician employees, preparation of personal development plans to address needed knowledge and skill areas, and funding to implement these plans. Recognizing the multiple training tracks by which physicians may come into a full-time public health career, the American Board of Preventive Medicine, the Board of Public Health Examiners, the American College of Preventive Medicine, the American Association of Colleges of Osteopathic Medicine, the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, the Association of Schools of Public Health, the American Public Health Association, and the Council of Accredited MPH Programs convene to explore the challenges and mechanisms available to assess minimum competency for physicians in public health practice. FUNDING Currently, public health training of physicians is funded through a number of mechanisms. For example, federal, state and local, and private entities offer education and training at various stages of a physician’s career or upon the entry of a physician into the workforce. However, funding adequate to support physician training in public health is a major issue for those practicing and seeking to enter the workforce. Reliable financial support of physician education and training in public health is lacking, as traditional funding sources are plagued by uncertain funding cycles and dwindling support. Another problem related to funding is that preventive medicine residency training tends to occur in nonhospital settings, such as community-based outpatient clinics and state and local health departments, which are ineligible for Medicare reimbursements. This leaves many preventive medicine residency programs scrambling for resources. As a result, most preventive medicine residencies rely heavily on other funding sources, for example, the Health Resources and Services Administration (HRSA). However, overall funding levels for HRSA health professions program budgets have steadily declined over recent years, from $10,473,000 in fiscal year 2002 to $7,920,000 in fiscal year 2006 (HRSA, 2006).

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Training Physicians For Public Health Careers Although funding for training programs is necessary to maintain an adequate supply of well-trained public health professionals, these programs alone cannot assure sufficient numbers of trained public health physicians. This is because serious challenges to attracting the necessary numbers of qualified physicians remain. The money-saving decisions made by many local governments have severely limited the numbers of physicians employed in health departments, confining them to clinical roles or those required by law and restricting them to working for the minimum number of hours legally possible. The importance of physician contributions to all public health policy has been diminished as the qualifications for public health agency leadership have expanded to include other public health practitioners. Furthermore, once a public health physician position is designated part time, the attention to the level of public health preparation of the incumbent may be minimal. The distribution and size of governmental public health agencies also mean that many public health physicians work in relative isolation from their peers. All of these forces combined have resulted in insufficient numbers of funded positions for part-time and full-time public health physicians. Furthermore, the salaries of public health physicians are significantly lower than those of their counterparts in private practice. Reliable financial support for physician education and training in public health is also lacking at the agency level. These challenges are more noticeable at the state level than at the federal level and are particularly acute at the local level, especially outside of major urban areas. Finally, other practical barriers to entering public health professions exist for physicians. For many physicians, their first introduction to public health may be after they are well into the development of their clinical practices and specialty interests, making it difficult to redirect their professional paths. Alternatively, when a physician who is already trained in medicine encounters the challenges and the potential of public health at mid-career, the lack of flexible training opportunities makes the development of the needed competency extremely difficulty. Several actions are necessary to facilitate physician training in public health and to maintain an adequate backbone public health physician workforce. The committee recommends that the U.S. Congress fund a comprehensive educational strategy sufficient to produce the additional number of public health physicians required through the following mechanisms: Funding for residency training in public health should be equivalent to and parallel the funding streams for graduate medical education in other medical disciplines.

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Training Physicians For Public Health Careers Funding to support the recommended expansion of the EIS and AHD programs. Reinstatement and growth of funding for health professions training through the Title VII programs. Congress fund Health Resources and Services Administration and the Centers for Disease Control and Prevention to work collaboratively to develop model demonstrations and evaluation programs that explore other models than direct physician hiring by health agencies. Such models might include regional physician health agency groups, development of public health expertise in larger health systems, or creation of a national network of consultants in specific public health domains. agencies, particularly state and local public health departments, create and adequately fund additional public health physician positions (full- and part-time) to accommodate the 10,000 additional public health physicians required. the American College of Preventive Medicine, the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, the U.S. Department of Health and Human Services, and the federal Office of Personnel Management regularly conduct a salary assessment of governmental public health and comparable private sector physicians. The agencies should use these results to align the salaries of their public health physicians to parity with private sector physicians performing comparable work. federal, state, and local public health agencies develop loan forgiveness programs for physicians who enter and continue to work in the public health sector. federal, state, and local public health agencies develop (or expand existing) programs that support public health training for physician employees in exchange for continued employment in that agency. employers of physicians in the public health workforce develop incentives to recruit and retain public health physicians that include discretionary benefits (e.g., leave, continuing education and conference support, portable retirement, etc.) ; career development support, based upon statewide or regional analysis of long-term public health physician needs across agencies, with support for further graduate training to physicians who agree to remain in public health, potentially moving to more responsible or more technically demanding positions over time; and

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Training Physicians For Public Health Careers opportunities for increased professional interaction for public health physicians practicing in remote or isolated circumstances. federal and state governments develop tax incentives for individuals who train and enter governmental public health. Public health physicians are vital to maintaining and improving the health of the public. The United States has an opportunity to build a strong public health physician workforce, but to do so requires commitment to actions that will overcome current barriers. If such commitment is forthcoming, the beneficiaries will be the people of the United States. REFERENCES ASTHO (Association of State and Territorial Health Officials). 2004. State public health employee worker shortage report: A civil service recruitment and retention crisis. Washington, DC: Association of State and Territorial Health Officials. Gebbie, K., and I. Hwang. 1998. Preparing currently employed public health professionals for changes in the health system. New York: Columbia University School of Nursing, Center for Health Policy & Health Services Research. Glass, J. K. 2000. Physicians in the public health workforce. In Update on the physician workforce. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration. Pp. 41-55. HRSA (Health Resources and Services Administration). 2006. Fiscal year 2007 justification of estimates for appropriations committees: Health professions. http://www.hrsa.gov/about/ budgetjustification07/publichealthworkforcedevelopment.htm (accessed May 11, 2006). IOM (Institute of Medicine). 1988. The future of public health. Washington, DC: National Academy Press. ———. 2003a. The future of the public’s health in the 21st century. Washington, DC: The National Academies Press. ———. 2003b. Who will keep the public healthy: Educating public health professionals for the 21st century. Washington, DC: The National Academies Press. Kennedy, V. C., W. D. Spears, H. D. Loe, Jr., and F. I. Moore. 1999. Public health workforce information: A state-level study. Journal of Public Health Management and Practice 5(3):10-19. Turnock, B. 2004. Public health: What it is and how it works. 3rd ed. Sudbury, MA: Jones and Bartlett.

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