AAMC Reporter: August 2007

New Report Urges More Public Health Training

More doctors should be more familiar with public health principles and practices as a means of promoting well-being, preventing disease, and preparing for public health emergencies, according to a new report issued by the Institute of Medicine (IOM) and co-sponsored by the AAMC. Requested by Congress in 2005, the report recommends boosting the overall number of public health physicians and improving public and preventive health training for all doctors throughout the medical education continuum.

"This important report highlights how essential physicians are to the public health workforce," said AAMC President Darrell G. Kirch, M.D. "We must take steps nationally to ensure a strong physician presence in public health programs, as well as work to make certain that tomorrow's doctors receive public health education throughout their careers."

A physician workforce more aware of public health issues could help Americans address the underlying causes of pressing health problems as opposed to solely the symptoms, report panelists said. For example, urologists who are knowledgeable about sexually transmitted disease transmission patterns in their community could help limit the spread of these diseases by informing patients as they are treated.

Dorothy S. Lane, M.D., M.P.H., director of the general preventive medicine and public health residency at Stony Brook University Health and Science Center School of Medicine, said the report is especially relevant given wide evidence of a steady national decline of public health physicians. According to a 2000 article in the American Journal of Preventive Medicine, the percentage of preventive medicine practitioners in the physician workforce has fallen by almost two-thirds, from 2.3 in 1970 to 0.9 in 1997.

"We just don't have enough people," said Lane, adding that limited financial resources restrict the number of preventive medicine residency slots."Most programs have to turn people away because they don't have enough funds for positions."

To address this shortage, the report, "Training Physicians for Public Health Careers," suggested establishing an additional 400 preventive medicine resident slots nationwide each year, at a minimum. The committee is also calling for 20,000 physicians in public health careers—a 100 percent increase over the current estimate. For the purposes of its recommendations, the report panel divided physicians into three basic groups: those with small, moderate, and high levels of involvement in public health and public health issues.

The report surmises that every physician touches the public health system in some capacity, and thus presumes that even doctors least involved in public health should have appropriate training in the field. As for undergraduate medical education, the report built on a 2003 IOM recommendation that all medical students be taught public health principles by adding preventive services, public health emergency preparedness, and similar principles to the list. Medical schools, said Rika Maeshiro, M.D., M.P.H., assistant vice president for public health and prevention in the AAMC's Division of Medical Education, said the 2003 recommendation bears repeating because academic medical institutions have not consistently responded to it.

As for physicians who are moderately involved with public health (e.g., pediatricians who work in school health and emergency physicians), the report recommended specialty-specific, competency-based certification programs and other training mechanisms.

For the most involved group—physicians with public health careers—the report recommends they have a master's degree in public health or comparable credentials or experience. To boost the number of these physicians, the report suggested that in addition to the proposed 400 additional preventive medicine residency slots, the Centers for Disease Control and Prevention (CDC) double current physician enrollment in its Epidemic Intelligence Service (EIS)—the nation's epidemiology training program—and that the Academic Health Department Program (AHD), instituted by the Association of Schools of Public Health through their cooperative agreement with the CDC, sustain 30 AHDs, partnerships between public health schools and health departments.

The report also makes sweeping recommendations for all those who are or will be in the medical education pipeline. During graduate medical education (GME), every physician should undergo training on specific public health concepts related to their specialty, according to the document.

"Residents start to see how different parts of the system begin to integrate together. [At] that point, your core practices and attitudes toward health care are crystallizing," said Brian J. McGrath, M.D., M.P.H., associate dean of GME at The George Washington University Medical Center. "Residency is the time to change attitudes and broaden perspectives about this system." Maeshiro agreed that GME is an important venue for teaching public health concepts and looks forward to AAMC participation in this endeavor.

"We hope to be able to expand these activities to residency programs and apply there what we have learned in undergraduate medical education," she said. Harold P. Freeman, M.D., associate director of the National Cancer Institute (NCI) and director of the NCI Center to Reduce Cancer Health Disparities, said the report held promise in respect to medical education, but wondered about the practicality of some specific suggestions regarding GME.

"I think the report makes a lot of sense," Freeman said. "Consider cancer. If people did not smoke cigarettes, a third of cancers would not occur. It appears that diet could prevent another third... But the specialties have become engorged with more and more to learn [clinically], so that they leave little room for anything else. You can train people to do things, but the system of medicine constricts doctors with respect to the time they have with patients. It is difficult to say 'Spend extra time telling patients not to smoke' when the HMO is saying they only have 15 minutes."

As with many issues in academic medicine and health care as a whole, the availability of funding is at the heart of the public health training discussion. The report recommends that federal funding be allocated for the expansion of the EIS and AHD programs, and greater financial incentives—including loan forgiveness—for physicians entering public health. These actions, said Lane, would help remedy the shortage.

"I think having more funds available will help a lot because it will heighten awareness. Even within the academic community, there is a certain lack of familiarity with preventive medicine and public health," said Lane.

Speaking specifically about preventive medicine residencies, Lane said that support for these programs has been a long standing issue because—unlike other residencies— they are not necessarily funded through Medicare. The report recommended that these residencies receive equivalent Medicare funding as clinical GME programs.

Training Physicians for Public Health Careers is available for purchase from the National Academies Press.

—Elissa Fuchs

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