3
Physician Training

This chapter explores the different pathways by which physicians come to careers in public health, examines population health as included in the medical education curriculum, describes both the degree and the nondegree public health training options for physicians, and makes recommendations about the kinds and numbers of training programs needed for physicians with different levels of involvement in public health.

PATHWAYS TO PUBLIC HEALTH CAREERS

Physicians enter careers in public health by different paths. Some enter public health through primary specialty training early in their careers or through joint programs sponsored by medical schools and schools or programs in public health. Historically, however, many physicians practicing public health have come to the field from clinical backgrounds, particularly primary care and infectious diseases. Although some physicians trained in clinical specialties make the transition to public health relatively early in their careers, for others a mid- or late-career change takes them to the field of public health. The next section explores these various pathways in more detail.



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Training Physicians For Public Health Careers 3 Physician Training This chapter explores the different pathways by which physicians come to careers in public health, examines population health as included in the medical education curriculum, describes both the degree and the nondegree public health training options for physicians, and makes recommendations about the kinds and numbers of training programs needed for physicians with different levels of involvement in public health. PATHWAYS TO PUBLIC HEALTH CAREERS Physicians enter careers in public health by different paths. Some enter public health through primary specialty training early in their careers or through joint programs sponsored by medical schools and schools or programs in public health. Historically, however, many physicians practicing public health have come to the field from clinical backgrounds, particularly primary care and infectious diseases. Although some physicians trained in clinical specialties make the transition to public health relatively early in their careers, for others a mid- or late-career change takes them to the field of public health. The next section explores these various pathways in more detail.

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Training Physicians For Public Health Careers Early Career Paths Preventive medicine residency is one route to a career in public health, typically taken early in a physician’s career, that provides a broad scope of public health training with both significant didactic experience and significant supervised practice experience. Physicians usually enter preventive medicine residencies either because they are interested in public health practice of some type or because they have an interest in research or practice related to clinical preventive services. Medical students may also choose to obtain a master of public health degree (M.P.H.) jointly with their medical degree through either an accredited school or program in public health. Another fairly direct route to a career in public health—and one that is frequently taken early in a physician’s career—is the 2-year Epidemic Intelligence Service (EIS) training program offered by the Centers for Disease Control and Prevention (CDC) and some states. The EIS program provides physicians (and other medical professionals) focused didactic experience and supervised field practice, specifically in epidemiology. This training may be very narrow (for example, primarily injury prevention research and interventions or communicable disease research and outbreak investigation) or somewhat broader (including management and policy experience), depending on the interest of the individual and the available field placements. Later Career Paths Some physicians choose to focus on population health in mid-career. Such physicians may have an established clinical or research practice and then become involved in administration, policy, or advocacy, perhaps in a somewhat narrow or specialized aspect of public health. An example might be a primary care physician who moves to work in a state or local public health setting. Other physicians may not become involved in population health until later in their careers. Such physicians may work in clinical settings within public health departments, either because they develop an interest in the population aspects of medicine because of the types of health problems that they have seen during their years of practice (e.g., excessive premature births, child injuries, or human immunodeficiency virus infections) or because they are interested in working in a setting in which they are not burdened with managing their own business. Physicians in mid- or late career have a number of educational options through which they may obtain the training needed to prepare them for careers in public health. These include pursuit of the M.P.H. degree, participation in certificate programs and public health training networks, and

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Training Physicians For Public Health Careers on-the-job training. The following sections describe the population health education provided by medical schools as well as specific approaches to public health education and training. CHANGING TRENDS IN TEACHING POPULATION HEALTH IN MEDICAL SCHOOLS At the beginning of the 1900s, medical education contained public health components (e.g., the study of infectious diseases) but was focused on biological systems. At that time neither distinct public health education programs nor any established career patterns for individuals to become public health physicians were in existence. Public health officers were physicians with their own private practices who responded to requests for assistance with epidemic diseases and other crises (Fee, 2003). At that time, public health was viewed as complementary to medicine, offering insights into sanitation and hygiene practices, clean water supplies, immunizations against diseases such as smallpox, and the prevention and control of the spread of contagious diseases (Beck, 2004). In 1910, the Flexner Report triggered much needed reform in medical education, including the standardization of preliminary education requirements and the development of a 4-year curriculum with 2 years of didactic training in basic science and 2 years of clinical training in a teaching hospital (Beck, 2004). With the growth in the amount of knowledge available in the field of medical science, medical education continued to develop through the biomedical model, focusing on disease, diagnosis, and cure. However, the conceptual and organizational model of medical education has remained largely unchanged over the past 100 years (Cooke et al., 2006). After World War II, interest in public health issues and training within medical schools increased; the medical curriculum continued to expand; and departments of preventive medicine, epidemiology, and social medicine were established or enhanced to teach such concepts and methods as epidemiology and biostatistics, prevention and health risk assessment, and, in some cases, economics and policy (Fee, 2003). It is noteworthy, however, that the Liaison Committee on Medical Education Accreditation Standards (June 2006) does not specifically require any education in public health, although it does require content and clinical instruction in preventive medicine, cultural competencies, and an understanding of common societal problems and how to address them. Most medical schools have incorporated some population health material into their curricula and have endorsed the need for medical schools to prepare physicians to respond to emerging public health challenges, such as bioterrorism events and public health emergencies. Table 3.1

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Training Physicians For Public Health Careers TABLE 3.1 Selected Topics Taught in U.S. Medical Schools, 2004– 2005 Topic Area Included in Required Course Included in Elective Course Biostatistics 125 41 Community health 113 71 Epidemiology 123 57 Nutrition 123 67 Population-based medicine 113 48 Prevention and health maintenance 118 58 Environmental health 90 43 Global health issues 74 58 Health determinants 89 36 Health policy development processes 74 42 Health care workforce 68 31 SOURCE: From the Liaison Committee on Medical Education Part II Annual Medical School Questionnaire for 2004-2005. Reprinted with permission. (AAMC, 2005). provides self-reported information on the areas of study offered by U.S. medical schools. Unfortunately, data about the specific content or depth with which each of these topics is covered, or the quality of the information provided are not available. Despite the incorporation of population-based concepts in medical school curricula, the pathways to public health practice are rarely direct. The next section discusses the career pathways that physicians may follow when they choose to enter public health. PUBLIC HEALTH EDUCATION: DEGREE TRAINING As discussed earlier, education in public health can be obtained in a variety of ways and at various points in a physician’s career. However, the different approaches do not provide a uniform set of knowledge and skills about public health. Physicians may receive degree training in public health through preventive medicine residencies that offer an M.P.H., including residencies provided through the armed forces, or from schools or programs in public health that culminate in an M.P.H. or equivalent degree. However, many physicians who engage in public health activities have no formal training in public health (Glass, 2000). Preventive Medicine Residencies Formal training in a preventive medicine residency is an important route for physicians seeking training and competence in public health. Preventive medicine is a unique medical specialty that provides a combi-

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Training Physicians For Public Health Careers nation of knowledge and skills in clinical medicine with those in population health. Preventive medicine specialists are trained to be competent in a number of core population health areas: biostatistics and epidemiology, environmental and occupational medicine, planning and evaluation of health services, management of health care organizations, research into the causes of disease and injury in population groups, and the practice of prevention in clinical medicine (ACGME, 2003). Specialists assume roles in various work settings by applying the knowledge and skills necessary to improve the health and well-being of individuals and entire communities. The preventive medicine residency model parallels that of other clinical specialties, including accredited programs with residency advisory committees and board certification. The American Board of Preventive Medicine grants certification in Public Health and General Preventive Medicine (PH/GPM), Occupational Medicine (OM), and Aerospace Medicine (AM). These disciplines or specialty areas have common core knowledge, skills, and competencies. The Preventive Medicine Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) oversees the accreditation of residency programs. Currently, 79 ACGME-accredited preventive medicine and subspecialty residency programs are available in the United States and enroll nearly 400 residents (ACGME, 2006). Of these programs, 40 focus on public health and general preventive medicine and have approximately 200 residents (ACGME, 2007). These programs are generally located in schools of medicine, schools of public health, state or local health departments, federal agencies, and military bases (ACPM, 2005b). In 2005 the American College of Preventive Medicine estimated that the average cost of residency training was $108,000 per resident per year (ACPM, 2005a). Unlike most graduate medical education programs, preventive medicine typically does not receive Medicare GME assistance through direct medical education reimbursement as most training tends to occur in non-hospital settings (ACPM, 2005c). As a result, programs often struggle to put together adequate funding packages for their residents relying on funding from a number of sources including institutional funds, Title VII (through the Health Resources and Services Administration), state and local agencies, voluntary health agencies, the Department of Veteran Affairs, foundations, and private corporations (Lane, 2000). Please see Chapter 4 for a detailed discussion of funding. To receive board certification, preventive medicine residents must successfully complete 3 years of specialty education and training. The 3-year residency program structure includes a clinical year, an academic year, and a practicum year. Although preventive medicine residency programs require clinical training, very few actually offer such training. As a result, most residents acquire their clinical training through an accredited

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Training Physicians For Public Health Careers TABLE 3.2 Number of Preventive Medicine Residents in ACGME-Accredited Programs, Academic Year Ending June 30, 2007 Specialty Area Number of Filled Positions Public Health and General Preventive Medicine 209 Occupational Medicine 118 Aerospace Medicine 27 primary care residency program, such as pediatrics, family medicine, or internal medicine, to fulfill the clinical requirement (ACPM, 2005b). These combined residency programs are an encouraging approach to solving some of the difficulties associated with obtaining clinical training. During the clinical segment, residents undertake a graduate year of clinical training that includes direct patient care. Preventive medicine residents must be able to demonstrate knowledge of and competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal skills and communication, professionalism, and systems-based practice (AMSA, 2005). The academic year involves training in preventive medicine, which leads to an M.P.H degree or an equivalent postgraduate degree. The final program year involves supervised field work or practical experience related to the resident’s specialty area, with placements generally lasting between 2 and 3 months (ACPM, 2005b). These assignments take place in a variety of professional settings and are structured to provide hands-on training for the resident. Table 3.2 provides data on the number of physicians in preventive medicine residencies in 2007. A graduate physician may choose a pathway to public health through a preventive medicine residency for several important reasons. Preventive medicine residencies offer established 2- to 3-year programs that can lead to board eligibility through a process analogous to the more clinically oriented residency programs. Preventive medicine residencies by their nature usually offer structured short- and long-term guidance and mentorship on the acquisition of public health practice skills in the chosen target areas, as well as career development and job placement opportunities. They also offer comradeship with other residents and coordinated didactic training. Many graduate physicians see strong value in having completed an accredited residency program that leads to board certification.

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Training Physicians For Public Health Careers Preventive Medicine in the Military The U.S. Army, Navy, and Air Force provide graduate medical education in preventive medicine. Physicians assume different public health roles within the military, however, given the various structures of the public health services required in the military. The basic function of public health services in the military is to support the public health needs of individuals working at local military installations and of the deployed forces. The military public health service also has a great deal of coordination and interaction with civilian health departments and services. Therefore, public health training in the armed forces incorporates both military and civilian health, and preventive medicine serves as the primary source of public health training for physicians in the military. The U.S. Army operates two residency programs in general preventive medicine, located at the Walter Reed Army Institute in Silver Spring, Maryland and the Madigan Army Center in Tacoma, Washington. The general preventive medicine residency is a combined program in which all residents receive additional instruction in occupational medicine, thereby facilitating board eligibility for two specialty areas in preventive medicine. Physicians in the U.S. Army tend to be placed in charge of the public health departments responsible for the local, regional, and national health services in the military. Public health physicians are also assigned to political positions, operational units, and academic and research positions. The majority of physicians assuming these roles possess a background in preventive medicine. The uniformed services of the United States sponsors graduate medical education for Medical Corps officers through the National Capital Consortium/Uniformed Services University of the Health Sciences (USUHS). The majority of physicians who are trained are U.S. Air Force and Navy officers, since the Army manages its own residency programs. USUHS serves as the second largest source of trained health care professionals entering the armed forces and offers the only U.S. Department of Defense-sponsored preventive medicine residency program that results in certification by the American Board of Preventive Medicine. The residency is a 2-year ACGME-accredited program with training available to military physicians who have completed a clinical postgraduate year and who are eligible for a medical license. The program also provides limited training opportunities to foreign military and U.S. Public Health Service physicians.1 Much like nonmilitary preventive medicine residency programs, residents complete an academic year at USUHS that leads to an M.P.H. or 1 Personal communication, R. D. Bradshaw, National Capital Consortium (NCC)/ Uniformed Services University (USUHS), January 22, 2007.

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Training Physicians For Public Health Careers a master of tropical medicine and hygiene degree, followed by a practicum year (USUHS, 2006). Public health physicians in the Navy serve not only the naval community but the Marine Corps as well. Naval preventive medicine physicians are often assigned to operational units within the Marine Corps, in addition to their standard public health roles. In addition to the residency training at the USUHS, the Air Force offers an aerospace medicine residency program. Much like the Army, the Air Force program is a combined program that allows year-long training in general preventive medicine and occupational medicine after completion of the year of training in aerospace medicine. The majority of preventive medicine trainees are aerospace medicine residents, with a small number entering the general preventive medicine program. These residents are usually board certified in a clinical subspecialty before they enter the general preventive medicine residency. Much of the public health training in the Air Force is nonpreventive medicine residency training and focuses on short-course instruction that is much more clinically focused (Mott, 2006). There are 29 available training slots per year in military programs that train General Preventive Medicine residents. However during 2006, no Air Force trainees chose the General Preventive Medicine tract so that for 2007 there will be 19 graduates from these programs.2 Schools and Programs of Public Health According to the Council on Education for Public Health, “The mission and goals of public health schools and programs are focused on preparation of individuals who will serve as practitioners, researchers, and teachers competent to carry out broad public health missions and goals, within and outside schools’ and programs’ institutional settings” (CEPH, 2007). The basic public health degree, the M.P.H. degree, is offered primarily through schools and programs of public health that also offer a variety of other public health-related degrees. Most people who receive formal education in public health are graduates of programs offered by these entities (IOM, 2003b). For those who wish to obtain advanced training, the doctor of public health is offered by schools of public health. Public health disciplines, such as epidemiology, the biological sciences, biostatistics, and the social and behavioral sciences, also offer academic degrees (e.g., the master of science and doctoral degrees) as well as joint degrees, such as the doctor of medicine degree and the M.P.H. and the doctor of osteopathic medicine degree and the M.P.H. 2 Personal communication, R. D. Bradshaw, National Capital Consortium (NCC)/ Uniformed Services University (USUHS), April 18, 2007.

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Training Physicians For Public Health Careers As this report is being written, the United States has 38 accredited schools of public health and 68 accredited M.P.H. programs, although nonaccredited schools and programs do exist. CEPH accredits schools of public health and public health programs offered in settings other than schools of public health. The Health Resources and Services Administration (HRSA) has been a major source of training funds for schools and programs of public health, however funding for public health workforce development has steadily declined. By 2002 health professions program funding levels had been reduced to $10,473,000. This amount was further reduced to $7,920,000 in 2006 (HRSA, 2006). For a detailed discussion of current funding please see Chapter 4. Schools of Public Health Of the 6,500 individuals who graduate each year from accredited schools of public health, approximately 15 percent (about 1,000) have a doctor of medicine degree (Spencer, 2006). Schools of public health vary in terms of size, organization, and the degrees that they offer. Yet, all schools have six major responsibilities (IOM, 2003b). These are to educate the educators, practitioners, and researchers as well as to prepare public health leaders and managers; serve as a focal point for multischool transdisciplinary research as well as traditional public health research to improve the health of the public; contribute to policy that advances the health of the public; work collaboratively with other professional schools to ensure a high-quality public health content in their programs; ensure access to lifelong learning for the public health workforce; and engage actively with various communities to improve the public’s health. All accredited schools of public health must offer courses in five core areas: biostatistics, epidemiology, environmental health sciences, health services administration, and social and behavioral sciences. The focus and content of courses within these areas vary, however. Schools also offer courses in a number of other areas, including nutrition, biomedical and laboratory sciences, disease control, and genetics. Additionally, accredited schools are required to have active research and public service programs. The Institute of Medicine (IOM) report addressing the education of public health professionals (IOM, 2003b) reaffirmed the importance of

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Training Physicians For Public Health Careers the five core areas mentioned above, as well as the idea that education should be competency based. That report also emphasized, however, that all public health professionals, including physicians, need to understand the ecological nature of the determinants of health and highlighted the importance of supervised practice opportunities. Furthermore, the report identified crucial gaps in the public health education curriculum, including informatics, communications, cultural competency, genomics, community-based research, global health, policy and law, and ethics. Currently, discussions are ongoing about how the recommended changes should be incorporated into the curriculum and the approaches that schools of public health use to educate public health professionals, including physicians. Finally, a 2002 survey of schools of public health found that most required a field placement or practicum as part of the educational experience, and more than half required a comprehensive written or oral final examination for a master’s or doctoral degree (IOM, 2003b). A capstone paper or project incorporating all aspects of the degree training program was also required by most schools. Programs in Public Health Public health programs offer education to a significant number of professionals entering public health. Unlike schools of public health, which are stand-alone schools in university settings, programs in public health are generally housed within other academic departments, colleges, or schools in university settings (for example, schools of medicine, osteopathy, or education). CEPH has accredited 68 of these programs. Accredited programs in public health are expected to be guided by the mission of “enhancing health in human populations, through organized community effort” and must be located within an accredited institution of higher education. These programs must also offer courses in the five core areas (biostatistics, epidemiology, environmental health sciences, health services administration, and social and behavioral sciences) and must pursue active research and public service programs (CEPH, 2007). Data from a 1999 survey indicated that about two-thirds of students in these more practice-oriented programs were participating in the program part-time (Davis and Dandoy, 2001). A report by Bialek and Bialek (1999) indicated that during the 1990s public health programs increased their emphasis on cross-disciplinary education and the use of problem-solving and case-based approaches to learning.

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Training Physicians For Public Health Careers NONDEGREE PUBLIC HEALTH EDUCATION AND TRAINING A number of physicians receive their public health education and training through informal programs and activities, such as certificate programs, public health training networks, leadership networks, and service programs and programs like the EIS. The approaches described below illustrate the growing movement to create training opportunities that accommodate the needs of the workforce. Certificate Programs Certificate programs are designed for those in public health practice who wish to further their knowledge or professional standing. Certificate programs may focus on one specific content area of public health or may emphasize core public health concepts in the five core areas of public health education: biostatistics, epidemiology, environmental health sciences, health services administration, and social and behavioral sciences. For example, the Graduate Certificate Program of CDC (which was begun in 1996 and, unfortunately, ended in 2001) was designed for CDC field officers, state health department personnel, and others who had at least 3 to 5 years of experience in public health practice. Those who completed the program earned a graduate certificate in public health from one of the schools through which the program was offered. Certificate programs provide a formal credential that, although it is not standardized, may be seen as indicating greater expertise than those without such training. Public Health Training Networks In 1993, the CDC, along with state, local, and academic partners, launched the Public Health Training Network (PHTN) to enhance the educational delivery system for the public health workforce. The PHTN was established to meet public health training and information needs through a range of instructional media and multimedia tools. Program participants are able to access network training resources through several media and multimedia options, including satellite-accessible resources, the World Wide Web, CD-ROM, videotape or DVD, audio bridge, on-site courses and conferences, and print media. The network has been quite successful in encouraging distance learning initiatives supported by state and federal agencies to address training and information needs (CDC, 2006). Several state health departments have also established training networks that serve their local workforces. Most of these networks usually link to the PHTN and partner with state and regional public health practice centers to enhance the level of instruction provided.

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Training Physicians For Public Health Careers M.P.H. graduate has mastered the knowledge and skills relevant to contemporary public health practice (NBPHE, 2007). Since public health has moved to focus on competency as a measure of work performance and educational achievement, competencies for the M.P.H. degree have been developed for each of the five core areas of knowledge (epidemiology, biostatistics, environmental health sciences, health services administration, and social and behavioral sciences). These five areas plus crosscutting areas similar to those recommended in the 2003 IOM report, Who Will Keep the Public Healthy, are being used by the NBPHE as they develop the voluntary certification examination for M.P.H. graduates. The Board expects to administer the certification examination in the summer of 2008. At this point it is difficult to assess the impact of this effort on physicians in public health careers. HOW MUCH TRAINING IS NEEDED? As discussed earlier in this report, the committee has identified three groups of physicians with different levels of involvement in public health: all physicians, those who practice public health for a limited amount of time or in a limited role, and physicians who choose a career in public health. Each of these levels requires a different amount of education about public health. All Physicians Training physicians in population-based medicine as well as clinical medicine holds strong promise for augmenting the quality and effectiveness of clinical practice. However, careful curriculum planning and creative approaches (e.g., case-based learning) are needed to integrate additional content areas into an already crowded medical school curriculum. Furthermore, continuous evaluation of these programs is essential to ensure that they are meeting the needs of clinicians, patients, and the public. The IOM report on educating public health professionals (2003b) recommended that medical schools provide all medical students with basic public health training (i.e., training in the population-based prevention approaches to health), that academic health centers undertake serious efforts to provide joint classes and clinical training in public health and medicine, and that a significant proportion of medical school graduates be fully trained in the ecological approach to health. “An ecological model assumes that health and well-being are affected by interaction among multiple determinants, including biology, behavior, and the environment. Interaction unfolds over the life course of individuals, families, and com-

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Training Physicians For Public Health Careers munities, and evidence is emerging that societal-level factors are critical to understanding and improving the health of the public” (IOM, 2003b). Because research has demonstrated that health is affected by multiple determinants, not just biology or medical care alone (IOM, 2006), it is important that physicians be aware of and take into account these other factors when they are deciding how best to treat patients. The view of health from an ecological perspective requires understanding of a problem or situation in terms of the multiple determinants of health. For example, a program designed to reduce high-risk pregnancies in teenagers must address family, cultural, nutritional, mental health, health care access, and even educational elements, along with challenging clinical issues. To use an ecological approach to affect health outcomes, one would develop interventions aimed at addressing the various determinants of health relevant to the desired health outcomes. For example, addressing the obesity epidemic requires cultural knowledge and leadership and community organizational skills, along with an awareness of genomics, physiology, treatment options (including surgery), and clinical complications, as well as nutritional education and programs (e.g., food stamps) aimed at ensuring an adequate supply of appropriate foods. Offering exercise facilities in the workplace may even enter the picture. The committee endorses the recommendation of the 2003 IOM report that all medical students receive basic education concerning the concept of determinants of health and the 13 content areas identified in that report (i.e., epidemiology, biostatistics, environmental health, health services administration, social and behavioral sciences, informatics, genomics, communication, cultural competence, community-based participatory research, global health, policy and law, and public health ethics). 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 the graduate levels; each graduate medical education program identify and include

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Training Physicians For Public Health Careers the 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 to physicians currently enrolled in medical education programs but also to those already practicing medicine, regardless of their specialty. Many currently practicing physicians, however, completed a medical education that had a less than complete basic public health content. 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. Physicians Engaged in Some Public Health Activities 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 public health concepts and skills because a specific portion of their practice, practice setting, or practice role involves public health. Many physicians have taken on specific public health-related roles and functions in their practices and would benefit from focused population health training. Examples of individuals in this group include infectious disease physicians who investigate health care-associated disease outbreaks, pediatricians working in school health, and emergency medicine specialists who direct emergency medical services. 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 assess-

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Training Physicians For Public Health Careers ments of the training needs of these physicians, the preparation of personal development plans to address needed knowledge and skill areas, and funding to implement these plans. Certificate programs, short-term intensive programs such as summer institutes, continuing medical education, and self-directed learning programs (e.g., distance learning) could be used to meet the training needs of this group of physicians. Although an abundance of short-term and distance learning programs on public health topics are available, an effort has not been made to develop competency-based assessment and training that could guide physicians to identify the course or program most appropriate for their specific training needs. Physicians with Careers in Public Health Preparing physicians for public health careers means providing training that enables them to meet the challenges facing public health today. Chronic diseases, obesity, and healthy aging are major issues at present, as are emerging infectious diseases, occupational and environmental exposures, the effects of globalization, poor mental health, and health disparities among different segments of the population. Advances in science and medical technologies and their use, which have contributed to improved health, are accompanied by important ethical, legal, and social questions. For example, new information on genomics can help identify people who are at increased risk of disease, target interventions, and be used to motivate individuals to engage in preventive behaviors; however, the use of genomic information to develop prevention and treatment plans that translate into positive behavioral changes is a tremendous challenge. Furthermore, genomics has the potential to widen disparities, “resulting in unbelievable advances and unbelievable inequities” (IOM, 2005). Whether physicians in public health practice full or part time, it is essential that their public health practice meets the current standards for public health professionals as well as any standards for specific applications relevant to their role as a public health physician or to the population 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 degree from schools or programs in public health or through preventive medicine programs; or acquire a comparable degree or experience (e.g., through the federal or state

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Training Physicians For Public Health Careers 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 identified. Beyond that, the depth of knowledge and skill in the content areas will be determined by the public health role that each physician plays. HOW MANY TRAINING PROGRAMS ARE NEEDED? One component of the charge to the committee was to determine the number of training programs needed to maintain an adequate supply of physicians trained for public health careers. As discussed earlier, 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 in The Future of the Public’s Health (IOM, 2003a), governmental public health agencies (i.e., federal, state, and local agencies) form

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Training Physicians For Public Health Careers the backbone of the public health system. These governmental agencies employ the core group of public health physicians who are the central focus of this report. As discussed in detail in Chapter 2, the estimated number of physicians currently in governmental public health practice is 10,000, with an estimated need for 20,000 physicians 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 must be increased. 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 level of participation in other disciplines. CDC expand its Academic Health Department (AHD) program to sustain 30 AHDs. The requirements should include the development of partnerships between the AHDs and medical schools to encourage physician participation. State and large local health departments, in conjunction with medical schools and schools of public health, expand postresidency fellowships in public health that emphasize the transition to 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 of an additional 400 residents each year. This expansion should be supported by federal general medical education funds that are not linked to the provision of clinical medical services. The Residency Review Committee for preventive medicine should review the content and quality of preventive medicine training programs in the context of the recommendations presented 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 should support both initial and ongoing assessments 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

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Training Physicians For Public Health Careers 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 to and mechanisms available for assessing the minimum competency required for physicians in public health practice. CONCLUSION The committee believes that it is important to maintain the incentives for and the ability of physicians to become career public health physicians through both degree programs and alternative pathways, such as certificate programs and the EIS program. Some might argue that this approach softens the rigor of the discipline and the credibility of the public health physician through a less than complete reliance on early and formal residency training. Others may believe that a more extensive clinical grounding brings expertise and credibility not provided by a traditional preventive medicine residency and might point to the many talented public health physician practitioners and leaders who lack a preventive medicine residency and board certification as proof of the wisdom of maintaining this alternate career path mechanism. Maintaining alternative pathways for education in public health cannot come at the expense of the training and competency of practicing public health physicians. However, it is unrealistic and potentially counterproductive to expect that all physicians, especially those making a mid-or late-career change, will take the time necessary to complete standard preventive medicine residency training or enroll in a school or program of public health. Physicians are a crucial part of the public health system, and as indicated in this chapter, many more public health physicians are needed to help meet the public health challenges facing the United States and, indeed, the world. Increasing the numbers of public health physicians is not enough—these physicians must also be prepared with the appropriate knowledge and skills to do their jobs well. The committee believes strongly that this can best be done by maintaining and strengthening multiple approaches to training, as described in this chapter.

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Training Physicians For Public Health Careers REFERENCES AAMC (Association of American Medical Colleges). 2005. Hot topics in medical education: Number of U.S. Medical schools teaching selected topics, 2004–2005. Washington, DC: Association of American Medical Colleges. ACGME (Accreditation Council for Graduate Medical Education). 2003. Program requirements for residency education in preventive medicine. Chicago, IL: Accreditation Council for Graduate Medical Education. ———. 2006. Number of accredited programs by academic year. http://www.acgme.org/adspublic/reports/accredited_programs.asp (accessed November 9, 2006). ———. 2007. Accredited program search. http://www.acgme.org/adspublic/ (accessed March 12, 2007). ACPM (American College of Preventive Medicine). 2005a. ACPM Board of Regents meeting/ communication. Preventive medicine residency costs. Washington, DC: American College of Preventive Medicine. ———. 2005b. Residency programs. http://www.acpm.org/residency.htm (accessed December 7, 2005). ———. 2005c. Statement of the American College of Preventive Medicine: Submitted to the Labor, Health and Human Services, Education, and related agencies Subcommittee. Committee on Appropriations United States House of Representatives for the record on fiscal year 2006 appropriations. Washington, DC: American College of Preventive Medicine. AMA (American Medical Association). 2007a. Definition of CME. https://ssl3.ama-assn.org/pra/praform.html (accessed March 4, 2007). ———. 2007b. State medical licensure requirements and statistics. http://www.ama-assn.org/ama1/pub/upload/mm/455/licensurereqs07.pdf (accessed March 4, 2007). AMSA (American Student Medical Association). 2005. FAQ about preventive medicine and its residency programs. http://www.amsa.org/cph/prevmed.cfm (accessed December 8, 2005). ASPH (Association of Schools of Public Health). 2006. Academic Health Departments: Pioneering academic-practice collaboration. Washington, DC: Association of Schools of Public Health. ———. 2007. Academic Health Department program. http://www.asph.org/document.cfm?page=950 (accessed February 21, 2007). Beck, A. H. 2004. The Flexner report and the standardization of American medical education. Journal of the American Medical Association 291(17):2139-2140. Bialek, R., and J. Bialek. 1999. Enabling the synergistic practice of public health and medicine through changes in public health education. In Education for more synergistic practice of medicine and public health. Edited by Hager, M. New York: Josiah Macy, Jr. Foundation. California Department of Health Services. 2007. California Epidemiologic Investigation Service (Cal-EIS) training program. http://www.dhs.ca.gov/CDIC/cdcb/pds/CALEIS/index.htm (accessed February 16, 2007). CDC (Centers for Disease Control and Prevention). 2006. Public Health Training Network: What is PHTN? http://www2.cdc.gov/PHTN/whatis.asp (accessed October 23, 2006). ———. 2007. Centers for Disease Control and Prevention: Fiscal year 2007 A-Z fact sheet: Epidemic Intelligence Service. Atlanta, GA: Centers for Disease Control and Prevention. CEPH (Council on Education for Public Health). 2007. Accreditation criteria graduate schools of public health. Amended January 2002. http://ceph.org/i4a/pages/index.cfm?pageid=3281 (accessed January 12, 2007). COGME (Council on Graduate Medical Education). 2000. Fifteenth report: Financing graduate medical education in a changing health care environment. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration.

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Training Physicians For Public Health Careers Cooke, M., D. M. Irby, W. Sullivan, and K. M. Ludmerer. 2006. Medical education: American medical education 100 years after the Flexner report. New England Journal of Medicine 355(13):1339-1344+1306. Cornell University. 2007. Public health post residency fellowships.http://www.med.cornell.edu/public.health/FellowshipPoster.07.pdf (accessed March 15, 2007). Davis, M., and S. Dandoy. 2001. Survey of graduate programs in public health and preventive medicine and community health education. Washington, DC: ATPM/HRSA. Fee, E. 2003. The education of public health professionals in the 20th century. In Who will keep the public healthy?: Educating public health professionals for the 21st century. Washington, DC: The National Academies Press. Florida Department of Health. 2007. Florida Epidemic Intelligence Service (FL-EIS). http://www.doh.state.fl.us/disease_ctrl/epi/FLEIS/Program_summary.htm (accessed February 16, 2007). 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. Hayes, M. 2006. Washington public health orientation program. Paper presented at Third Meeting of the Committee on Training Physicians for Public Health Careers, Washington, DC. 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). ———. 2007a. Fiscal year 2007 justification of estimates for appropriations committees: Health professions—National Health Service Corps. http://www.hrsa.gov/about/budgetjustification07/NationalHealthServiceCorps.htm (accessed March 8, 2007). ———. 2007b. National Health Service Corps: 35 years of service to the underserved (factsheet). http://nhsc.bhpr.hrsa.gov/publications/factsheets.asp (accessed February 26, 2007). ———. 2007c. National Health Services Corps: About NHSC. http://nhsc.bhpr.hrsa.gov/about/ (accessed February 26, 2007). IOM (Institute of Medicine). 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. ———. 2005. Implications of genomics for public health: Workshop summary. Washington, DC: The National Academies Press. ———. 2006. Genes, behavior, and the social environment: Moving beyond the nature/nurture debate. Washington, DC: The National Academies Press. Keck, C. W. 2000. Lessons learned from an academic health department. Journal of Public Health Management and Practice 6(1):47-52. Lane, D. S. 2000. A threat to the public health workforce: Evidence from trends in preventive medicine certification and training. American Journal of Preventive Medicine 18(1):87-96. Langmuir, A. D. 1980. The Epidemic Intelligence Service of the Center for Disease Control. Public Health Reports 95(5):470-477. McDowell, D., and N. Gibbs. 2006. Distance learning in public health. http://www.phf.org/Link/LINK12-1DL.htm (accessed October 24, 2006). Mott, R. L. 2006. Military health. Paper presented at Second Meeting of the Committee on Training Physicians for Public Health Careers, Washington, DC. NBPHE (National Board of Public Health Examiners). 2007. About NBPHE. http://www.nbphe.org/ (accessed January 22, 2007).

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Training Physicians For Public Health Careers Public Health Foundation. 2007. Public health workforce development: TRAIN - TrainingFinder Real-time Affiliate Integrated Network. http://www.phf.org/phworkforce.htm (accessed January 28, 2007). Rowitz, L. 2001. Public health leadership: Putting principles into practice. Sudbury, MA: Jones and Bartlett. Saint Louis University School of Public Health. 2005. National Public Health Leadership Development Network. http://www.heartlandcenters.slu.edu:16080/nln/index.html (accessed December 13, 2005). Spencer, H. C. 2006 April 27. IOM Committee on Training Physicians for Public Health Careers. Paper presented at Meeting of the Committee on Training Physicians for Public Health Careers, Washington, DC. Tilson, H. H., and K. M. Gebbie. 2001. Public health physicians: An endangered species. American Journal of Preventive Medicine 21(3):233-240. USUHS (Uniformed Services University of the Health Sciences). 2006. USUHS Department of Preventive Medicine and Biometrics. http://www.usuhs.mil/pmb/index.html (accessed May 15, 2006).

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