Levy, Barry S. MD, MPH; Wegman, David H. MD, MSc
Medical instruction does not exist to provide individuals with an opportunity of learning how to make a living, but in order to make possible the protection of the health of the public.
—Rudolf Virchow, Lecture to medical students, 18481
A pediatrician correctly diagnoses lead poisoning in a 4-year-old child, but he fails to take adequate measures to identify cases of lead poisoning among other children living in the same building.
A family physician diagnoses chronic lung disease in a 45-year-old male industrial worker, but she does not recognize that occupational exposure to silica caused it; she is, therefore, unable to help protect the patients’ coworkers who are being similarly exposed.
An internist correctly diagnoses and treats an upper respiratory infection in a 34-year-old woman, but he fails to address her cigarette smoking habit.
A family physician provides prenatal care to a pregnant teenager, but she overlooks the opportunity to promote a school health clinic that could provide education, information, and services to prevent unwanted pregnancies among other teenagers.
An internist sees three adult patients from the same community, all of whom have the same unusual serious respiratory disease, but he fails to report this cluster to the state health department.
These are but a few of the many examples in which clinicians, caring well for each patient, may fail to recognize and act on opportunities to prevent disease and promote health in the patient and fail to protect the health of the public.
The article by Loh and Peik2 titled “Public health physician specialty training in Canada and the United States” in this issue of Academic Medicine provides interesting and useful information concerning the training of public health and preventive medicine physician specialists in the two countries. But such specialists represent a very small fraction of the total number of physicians in each country. Although these physician specialists contribute to the public’s health in many ways, such as by conducting epidemiologic studies and influencing the development of public policy, a substantial additional benefit could be achieved by ensuring that all medical students and residents enter practice with substantive knowledge and practical skills in public health and preventive medicine. Such knowledge and skills would enable physicians to be more effective in improving and maintaining the health of patients as well as the health of communities and larger populations.
More extensive education and training in public health and preventive medicine for all physicians would enable them, at the individual patient level, to be more effective in such areas as
* Working with patients in the context of their socioeconomic environments to address their lifestyle choices in order to reduce their disease risk factors and improve their health status;
* Identifying and reducing occupational and environmental risk factors to prevent injuries and illnesses; and
* Empowering patients to effectively manage their own chronic health conditions, such as diabetes mellitus and coronary artery disease, in the context of their work demands and work schedules.
In addition, at the community and population levels, more extensive education and training in public health and preventive medicine for all physicians would enable each of them to play more active and more influential roles in bringing about long-lasting systemic changes, such as those related to
* The implementation of the Patient Protection and Affordable Care Act in the United States;
* The development of accountable care organizations3 and “global payment plans”4; and
* The increased use of tools and analyses associated with electronic health records and other forms of health information technology.
The time has come for transformations in how physicians view public health and preventive medicine and in how they are educated and trained. The time has come for a paradigm shift from the current context in which medical care has a limited overlap with public health and preventive medicine (Figure 1A) to one in which medical care occurs within the context of public health and preventive medicine (Figure 1B). Operating within this transformed context, all physicians—not only a small fraction of them—would receive extensive education and training in public health and preventive medicine. Patients, their communities, and larger populations would benefit in innumerable ways.
Providing specific details of transformed curricula for medical students and residents is beyond the scope of our commentary; however, the academic medicine community should consider the following broad elements for educating and training physicians in public health and preventive medicine:
* A life-course approach that considers the roles of physicians and other health professionals in promoting health and preventing disease at each stage of life;
* Knowledge of both the theoretical bases and the day-to-day practical skills for practicing medicine in the context of public health and preventive medicine; and
* Team approaches in which various types of health professionals work together to improve the health of the patients and the communities they serve.
Now is the time to make public health and preventive medicine a core component of medical education and training. Leaders in medical education are advocating such a paradigm shift. For example, a major conclusion from the 2010 “Patients and Populations: Public Health in Medical Education” symposium,5 sponsored by the Association of American Medical Colleges and the Centers for Disease Control and Prevention, was as follows:
Emerging information about the impact of the social determinants of health on health status, the focus of the Affordable Care Act on prevention and wellness, and the poor showing of the U.S. among the developed nations of the world in terms of population health all suggest that a major paradigm shift in medical education and practice has become a necessity. Efforts to develop health professionals who can improve health, and not just deliver health care, should be a continuing priority for the academic medicine and public health communities.
Similarly, the General Medical Council in the United Kingdom has reemphasized public health education for medical students. It has stated that medical school graduates
must understand the issues and techniques involved in studying the effect of diseases on communities and individuals, including:
(a) assessing community needs in relation to how services are provided;
(b) genetic, environmental and social causes of, and influences on the prevention of, illness and disease; and
(c) the principles of promoting health and preventing disease, including surveillance and screening.6
The General Medical Council has also promoted a specific framework of questions to facilitate the integration of public health into the curricula of medical schools6:
1. What public health issues are raised by this problem?
2. How does this problem affect the population (who, when, where, by how much, and why)?
3. What are the health needs of the population in relation to this problem?
4. How can the burden of this problem be reduced?
5. How should health (and other) services be organized and delivered to address this problem?
6. What are the main research and development issues raised by the problem?
7. What are the main public health policy implications of this problem?
The Institute of Medicine has defined public health as “what we, as a society, do collectively to assure the conditions in which people can be healthy.”7 Therefore, public health and preventive medicine must be integral to any nation’s health system. Yet, in both the United States and Canada, only a small fraction of health expenditures are used for the prevention of disease and the promotion of health, and only a small fraction of physicians specialize in public health and preventive medicine.2 Priorities in both countries need to change. All medical students and residents should be functionally prepared so that they can—and do—integrate public health and preventive medicine into medical care.
When physicians are so educated and trained, we can envision a future in which they would not only diagnose and treat illness, but also act on opportunities to prevent disease and promote health in their patients and to protect the health of the public:
A pediatrician correctly diagnoses asthma in a 4-year-old child, and he then takes adequate measures to assist the child’s parents in identifying and controlling triggers of asthmatic attacks in the child’s home environment.
A family physician correctly diagnoses carpal tunnel syndrome in a 45-year-old male industrial worker, and she recognizes that the forceful, repetitive motions of his work caused it; she then takes steps to ensure that work tasks and practices are redesigned to prevent future musculoskeletal disorders in this worker and his coworkers.
An internist correctly diagnoses bronchitis in a 34-year-old woman who has just returned from military service in the war in Afghanistan and recognizes that she is experiencing much stress in reintegrating into her family and community; he refers her to a psychologist and to a veterans’ support group and arranges for a follow-up visit to monitor her progress.
A family physician diagnoses obesity in a teenage boy and advises him on how to lose weight; she then works with a school health nurse in establishing a program to provide information to other teenagers on healthy food choices and physical exercise.
An internist sees three patients from the same community, all of whom have recent onset of nausea, vomiting, and abdominal pain; he then reports this cluster to the state health department, which investigates the outbreak, determines that it was caused by food contamination, and implements additional measures to prevent food-borne disease.
In this transformed context, medical instruction exists, as Virchow lectured 164 years ago, “to make possible the protection of the health of the public.”1
Other disclosures: None.
Ethical approval: Not applicable.
Disclaimers: The views expressed are those of the authors and should not be construed to represent the positions of educational institutions or other organizations with which they have been affiliated.