TRAINING PHYSICIANS FOR PUBLIC HEALTH CAREERS

Committee on Training Physicians for Public Health Careers

Board on Population Health and Public Health Practice

Lyla M. Hernandez and A. Wezi Munthali, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu



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Training Physicians For Public Health Careers TRAINING PHYSICIANS FOR PUBLIC HEALTH CAREERS Committee on Training Physicians for Public Health Careers Board on Population Health and Public Health Practice Lyla M. Hernandez and A. Wezi Munthali, Editors INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Training Physicians For Public Health Careers THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. D1DHP06515 between the National Academy of Sciences and HRSA-Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Training physicians for public health careers / Committee on Training Physicians for Public Health Careers, Board on Population Health and Public Health Practice ; Lyla M. Hernandez and A. Wezi Munthali, editors. p. ; cm. Includes bibliographical references. ISBN-13: 978-0-309-10760-0 (pbk. (perfect bound) : alk. paper) ISBN-10: 0-309-10760-1 (pbk. (perfect bound) : alk. paper) 1. Public health personnel—Training of—United States. 2. public health personnel—Supply and demand—United States. I. Hernandez, Lyla M. II. Munthali, A. Wezi. III. Institute of Medicine (U.S.). Committee on Training Physicians for Public Health Careers. [DNLM: 1. Education, Public Health Professional—United States. 2. Physicians—United States. 3. Public Health—manpower—United States. WA 18 T7687 2007] RA440.9.T73 2007 362.1068′3—dc22 2007025376 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2007 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2007. Training physicians for public health careers. Washington, DC: The National Academies Press.

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Training Physicians For Public Health Careers “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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Training Physicians For Public Health Careers THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Training Physicians For Public Health Careers COMMITTEE ON TRAINING PHYSICIANS FOR PUBLIC HEALTH CAREERS RICHARD B. JOHNSTON, JR. (Chair), Associate Dean, Professor, Executive Vice President, University of Colorado School of Medicine and National Jewish Medical and Research Center, Denver SUSAN M. ALLAN, Public Health Director, Oregon Department of Human Services, Portland GEORGES C. BENJAMIN, Executive Director, American Public Health Association, Washington, DC DAN G. BLAZER, J.P. Gibbons Professor, Duke University Medical Center, Durham, NC LINDA H. CLEVER, Chief, California Pacific Medical Center, Mill Valley DAVID W. FLEMING, Director, Department of Public Health, Seattle/King County, Washington KRISTINE M. GEBBIE, Assistant Professor of Nursing and Director, Center for Health Policy, Columbia University School of Nursing, New York LEWIS R. GOLDFRANK, Professor, Chair, and Director of Emergency Medicine, New York University School of Medicine, Bellevue Hospital Center, and New York University Medical Center JAMES M. HUGHES, Director, Program in Global Infectious Disease, Center for Global Safe Water, Emory University, Atlanta, GA NICOLE LURIE, Senior Natural Scientist and Paul O’Neill Alcoa Professor, The RAND Corporation, Arlington, VA TARA A. MCCARTHY, Consultant, Boston Public Health Commission, MA LOUIS ROWITZ, Professor, University of Illinois at Chicago JOSEPH J. SCHWERHA, Professor and Director, Occupational and Environmental Medicine Residency, Graduate School of Public Health, University of Pittsburgh, PA ROBERT WALLACE, Irene Ensminger Steecher Professor of Epidemiology and Internal Medicine, University of Iowa, Iowa City Staff LYLA M. HERNANDEZ, Senior Program Officer A. WEZI MUNTHALI, Research Associate MATT SOLYST, Project Assistant (until April 2007) ROSE MARIE MARTINEZ, Director, Board on Population Health and Public Health Practice

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Training Physicians For Public Health Careers Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: THOMAS BECKER, Department of Public Health and Preventive Medicine, Oregon Health & Science University LESLIE BEITSCH, Center on Medicine and Public Health, Florida State University College of Medicine MARY DES VIGNES-KENDRICK, The Division of Management, Policy and Community Health and Center for Biosecurity and Public Health Preparedness, University of Texas School of Public Health WILLIAM E. HALPERIN, Department of Preventive Medicine and Community Health, University of Medicine and Dentistry, New Jersey ROBERT G. HARMON, Duval County Health Department, Jacksonville, Florida

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Training Physicians For Public Health Careers MARGARET A. POTTER, Center for Public Health Practice, Graduate School of Public Health, University of Pittsburgh WILLIAM SCHAFFNER, Department of Preventive Medicine, Vanderbilt University School of Medicine JOHN SWARTZBERG, University of California, Berkeley School of Public Health & University of California, San Francisco, School of Medicine Joint Medical Program and UC Berkeley Wellness Letter Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Dr. David R. Challoner, Vice President for Health Affairs, Emeritus, University of Florida and Dr. Linda Rosenstock, Dean, School of Public Health, University of California, Los Angeles. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Training Physicians For Public Health Careers Acknowledgments The committee is grateful to the many people who shared their expertise and insights over the course of the study. Their contributions were crucial to the committee deliberations. The study sponsors at the Health Resources and Services Administration, the Centers for Disease Control and Prevention, and the Association of American Medical Colleges willingly responded to questions and provided information and data related to the topic of the study. In particular, the committee wishes to thank Tanya Pagan Raggio Ashley, Denise Koo, and Rika Maeshiro. Speakers at the three public meetings provided a broad overview of issues related to training physicians for public health careers. The committee greatly appreciates the input of those speakers: George K. Anderson, Jo Ivey Boufford, Karen Fisher, Charles Godue, Arvind Goyal, Maxine Hayes, Paul E. Jarris, Denise Koo, Patrick Libbey, Robert L. Mott, Andre-Jacques Neusy, Joel L. Nitzkin, Michael Parkinson, Tanya Pagan Raggio Ashley, Anthony L. Schlaff, Harrison C. Spencer, Hugh H. Tilson, and Michael E. Whitcomb. Joel Nitzkin made substantial additional contributions to the committee’s work. The committee was extremely fortunate in its staffing for this study and wishes to thank our study director, Lyla M. Hernandez, for her overall management of the process and her efforts in producing a clearly written, well-organized report that reflects the collective thought of the committee. We also wish to thank Wezi Munthali, Research Associate, for her superb research support and written contributions. Matt Solyst provided particularly effective and much appreciated administrative support.

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Training Physicians For Public Health Careers Contents     SUMMARY   1 1   FUNDAMENTALS: THE HEALTH OF THE PUBLIC IS THREATENED   15      Public Health in the United States,   16      The Current State of Public Health Structure and Practice,   17      Physicians and the Nature of Public Health Practice,   18      Physician Contributions to Public Health,   22      Context,   25      Conclusion,   26      References,   27 2   PHYSICIANS IN PUBLIC HEALTH: THEIR ROLES, KNOWLEDGE NEEDED, AND NUMBERS   29      Roles and Levels of Engagement,   29      What Do Physicians Need to Know?,   31      Number of Public Health Physicians,   39      How Many Public Health Physicians Are Needed?,   42      Conclusion and Recommendations,   45      References,   46 3   PHYSICIAN TRAINING   49      Pathways to Public Health Careers,   49      Changing Trends in Teaching Population Health in Medical Schools,   51

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Training Physicians For Public Health Careers      Public Health Education: Degree Training,   52      Nondegree Public Health Education and Training,   59      Supporting Mechanisms,   62      Credentialing,   67      How Much Training Is Needed?,   68      How Many Training Programs Are Needed?,   72      Conclusion,   74      References,   75 4   FUNDING   79      Current Funding Approaches,   80      Title VII: A National Training Resource,   81      Other Federal Funding,   86      Other Funding Mechanisms,   88      Recommendations,   89      Conclusion,   92      References,   92 5   CONCLUSION   95      References,   97     APPENDIXES     A   Recommendations from The Future of the Public’s Health in the 21st Century   99 B   Glossary and Acronyms   107 C   Agendas of Open Session Committee Meetings   109 D   Committee Biographies   115 TABLES, FIGURES, AND BOXES TABLE 2.1   Public Health Content Areas for Physician Training,   33 TABLE 2.2   Estimated Present and Future Numbers of Physicians in Governmental Public Health Agencies,   43 TABLE 3.1   Selected Topics Taught in U.S. Medical Schools, 2004–2005,   52 TABLE 3.2   Number of Preventive Medicine Residents in ACGME-Accredited Programs, Academic Year Ending June 30, 2007,   54 TABLE 3.3   Numbers of EIS Officers (1997 to 2006) and Percentage of Physicians in Each Class,   61

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Training Physicians For Public Health Careers TABLE 4.1   Title VII Health Professions Programs Relevant to Physician Training,   82 TABLE 4.2   Health Professions Program Funding Levels, FYs 2002 to 2006,   85 FIGURE 1.1   Framework of the report The Future of the Public’s Health in the 21st Century,   19 FIGURE 2.1   Physician involvement in public health,   30 BOX 1.1   Selected Recommendations from The Future of the Public’s Health in the 21st Century,   20

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