A threat to the public health workforce: evidence from trends in preventive medicine certification and training

Evidence of a growing need for preventive medicine specialists is the congruence between needed competencies for practice in the current health care environment, as identified by the Council on Graduate Medical Education (COGME) and in other national reports, and the core competencies of preventive medicine residents. The total number of certified specialists in preventive medicine is 6091. The proportion of self-designated preventive medicine specialists among all U.S. physicians is on the decline and the greatest decline has been among those in public health (PH) and general preventive medicine (GPM). In addition, the total number of preventive medicine residents is on the decline, and the decline has been greatest among those training in PH and combined PH/GPM. One of the reasons for this decline has been inadequate funding due to the absence of Medicare graduate medical education (GME) financing for population-based vs. individual patient care services and meager and diminishing Title VII support. A paucity of faculty is apparent in medical schools with residency training and board certification in preventive medicine. Several actions may help reverse this trend and assure adequate numbers of preventive medicine specialists: expansion of Title VII to increase the number of residents receiving stipends and tuition, adding infrastructure support for faculty development and funding of demonstration projects in distance learning and in joint generalist/ preventive medicine residency training. Medicare GME reform should include recognition of population-based services and inclusion of preventive medicine residencies in provisions for "nonhospital-based" training and in up-weighting methodologies for primary care training. Expansion of Veterans Affairs, National Institute for Occupational Safety and Health, and Department of Defense support is also needed as is attention to resident debt reduction.     

The preventive medicine physician: a national study

Following the 1980 Graduate Medical Education National Advisory Committee report, postal questionnaires were sent to a random sample of physicians self-designated as preventive medicine specialists primarily in an effort to verify the committee's assumption that preventive medicine is not a clinical specialty. The questionnaires represented each of the preventive medicine subspecialties: general preventive medicine, public health, occupational medicine, and aerospace medicine. After three reminders, 419 out of 942 (44%) responded. Seventy percent of the physicians who responded engage in clinical activities for at least part of their workweek. Preventive medicine is practiced in a wide variety of settings. For the majority of preventive medicine physicians, prevention plays an important role in their practice. They perceive that they practice medicine differently from their colleagues who are not preventive medicine specialists because of their prevention focus. Many of these physicians have made career changes, and some have made many such changes, as board certification in one of the subspecialties does not preclude practice in another subspecialty. The specialty appears to allow considerable flexibility. The preventive medicine physician is prepared to incorporate prevention into clinical practice and seems well equipped to integrate community and individual clinical approaches.     

The occupational medicine consultant

The occupational medicine consultant emerged in a few areas of the country during the 1940s. The concept is growing in popularity, with some recent evidence indicating that it may be the dominant career path for residency trained specialists in occupational medicine. The services provided to industry, labor, and government do not appear to compete with traditional occupational medicine positions. The manpower shortage in occupational physicians promises to fuel the growth opportunity for occupational medicine consultants. The major concerns at this time are the adequacy of liability insurance carried by the consultants and the possibility that their activities will too often be related to crisis situations rather than to the development of preventive medical programs with their clients.     

Bronchial Epithelial Mucin in Rats Infected With Mycoplasma pulmonis

After 80 years, US training for clinical specialties is essentially hospital-based supervised practice. Needs for specialists are barely met, particularly since one third of residents are foreign citizens. Training must be more efficient, shorter, and relevant to community practice. Numbers of trainees in preventive medicine are entirely inadequate. Residencies have grown rapidly, but comprise only 1% of programs and positions. Younger physicians are recruited through community impact on health care, students, and teachers. These preventive medicine residents function outside hospitals, work fewer hours, are paid more than clinical residents, and obtain an academic year’s graduate education. They work fewer hours, but receive less pay than clinicians. The nation must examine the concept of training physicians for nonclinical preventive medicine functions and, if training continues, must develop methods of making training and career more attractive.     

Regaining the preventive medicine edge: training for 2000 and beyond

We review the state of preventive medicine in the context of four factors that have eroded the influence and effectiveness of the specialty: (1) historical; (2) cultural; (3) political-economic; and (4) changing epidemiological and demographic factors. We address the implications for public and medical peer recognition of preventive medicine, for funding of residency programs, and for recruitment of medical students. We outline five objectives for preventive medicine training as steps to improve the response of the specialty to the above factors and to regain its edge. Also, we propose two specific innovative training programs to partially meet these objectives: a cross-cultural public health exchange and a preventive medicine fellowship in policy and public administration. We discuss the pertinence of these programs in terms of reversing preventive medicine's growing obsolescence.     

The need for black specialists in preventive medicine

The disparity in health status between black and white Americans exists chiefly because of an excess of preventable disease in blacks. This situation calls for an increase in preventive services for blacks, services which might best be implemented or directed by black specialists in preventive medicine. However, there exists both an absolute shortage of preventive medicine specialists (of all races) and a relative shortage of black preventive medicine specialists. The immediate need for additional black specialists exceeds the total U.S. preventive medicine residency corps.     

Competencies for population-based clinical managers: A survey of managed care medical directors

Background: The evolution of American health care into integrated systems of delivery and finance requires a specialized set of population-based skills for physicians. The field of preventive medicine represents one source of this expertise. Specific competencies for the emerging area of managerial medicine have not been well delineated.Methods: Using concept documents from the Residency Review Committee for Preventive Medicine and the American Board of Preventive Medicine, a list of proposed competencies for managerial medicine was identified. Surveys were mailed to medical directors of all members of the American Association of Health Plans and to a random sample of diplomates of the American Board of Preventive Medicine. Respondents were asked to rate the importance of these competencies for a population-oriented clinician manager.Results: Areas rated highly by medical directors included health services research (including outcomes research), quality assurance and improvement, health risk assessment and reduction, programmatic skills, and clinical preventive skills. Responses from preventive medicine specialists were similar, but placed lower emphasis on these skills.Conclusion: Despite its limited response rate, this survey may be useful in the implementation of specialty training in managerial medicine. Residency training programs may choose to emphasize specific content areas that reflect the priorities expressed by physicians actively involved in management.     

The postgraduate education of physicians in preventive medicine

The Graduate Medical Education National Advisory Committee report projected a serious shortage of preventive medicine specialists in 1990, and the recommendations of a recent report from the Association of American Medical Colleges called for increased training of medical students in health promotion and disease prevention and in adapting to changes in health and health care. To help meet the need for physician manpower in preventive medicine a new residency was established at the State University of New York at Stony Brook in July 1983. The program features a structured approach to the practicum year, incorporating an organized core curriculum and opportunities for a varied field experience. In addition to the School of Medicine and University Hospital, major training sites include two large county health departments on Long Island, three community hospital departments of community medicine, a health maintenance organization as well as several neighborhood health centers, and community-based programs operated by these hospitals and health departments. The curriculum includes both longitudinal experiences at the medical school involving teaching, research, and didactic conferences, and block field rotations within the above affiliated agencies, providing practice experience in preventive medicine and public health. The diversity in the organization and type of preventive medicine institutions used for training enriches the residency experience and is complemented by core educational activities.     

Learning objectives for training and continuing education in occupational medicine.

Occupational medicine (OM) training programs apparently vary more in content and practice skills than other medical special training programs. This variation appears to exist both within programs, in that individual trainees in some programs may engage in very different experiences, and between programs. Some variation is not necessarily undesirable, considering the multiplicity of professional roles, the eclectic backgrounds of many residents, and the diversity of points of view in each of the specialties. However, excessive variation in medical content and practice skills in the training experience may result in uneven training and, in fact, undermines the integrity of the specialty. A consensus on core content and skills for specialty training might help. A consensus would help physicians to judge their own level of preparation in order to decide to participate in further training and continuing education programs. I prepared a model set of objectives for occupational medicine under the auspices and with the endorsement of the American College of Preventive Medicine. Further evaluation can refine the objectives, implement use of the objectives in formal training programs, and assess the utility of the format for other preventive medicine specialties.     

Legal Requirements For Immunizations

The gigantic problem of controlling environmental pollution has been clearly recognized. A severe shortage of environmental health manpower has also been recognized and reported. Every available source must be investigated and utilized. The training and experience of US Air Force, US Army, and US Navy military preventive medicine subprofessional personnel are excellent and comprehensive. Although there are minor differences in emphasis between services, these personnel have training and experience sufficient to make them a valuable resource in the solution of environmental control programs. Fairly significant numbers are available each year and they can be utilized in civilian environmental programs. Although there are many problems In utilizing subprofessional personnel, action should be taken to insure maximum utilization of this important resource of environmental health manpower.     

社区卫生技术人员知识与技能需求及影响因素分析

通过对社区卫生服务站社区卫生技术人员知识与技能需求调查分析 ,表明社区卫生技术人员知识与技能不能满足城市居民日益增长的医疗保健需求 ,大部分社区卫生知识与技能的掌握程度一般 ,急需培训的课程主要是预防保健专业知识 ,急需提高的社区卫生服务技能主要是社区康复技能、急诊社区处理、心理学、社会医学、预防医学、健康教育、流行病学方法等。社区卫生知识与技能的掌握程度与培训需要有关。本次调查为社区卫生服务人员继续教育提供了参考依据     

Equity in prevention and health care

STUDY OBJECTIVE: There is an increasing body of evidence about socioeconomic inequality in preventive use, mostly for cancer screening. But as far as needs of prevention are unequally distributed, even equal use may not be fair. Moreover, prevention might be unequally used in the same way as health care in general. The objective of the paper is to assess inequity in prevention and to compare socioeconomic inequity in preventive medicine with that in health care. DESIGN: A cross sectional Health Interview Survey was carried out in 1997 by face to face interview and self administered questionnaire. Two types of health care utilisation were considered (contacts with GPs and with specialists) and four preventive care mostly delivered in a GP setting (flu vaccination, cholesterol screening) or in a specialty setting (mammography and pap smear). SETTING: Belgium. PARTICIPANTS: A representative sample of 7378 residents aged 25 years and over (participation rate: 61%). Outcome measure: Socioeconomic inequity was measured by the HI(wvp) index, which is the difference between use inequality and needs inequality. Needs was computed as the expected use by the risk factors or target groups. MAIN RESULTS: There was significant inequity for all medical contacts and preventive medicine. Medical contacts showed inequity favouring the rich for specialist visits and inequity favouring the poor for contacts with GPs. Regarding preventive medicine, inequity was high and favoured the rich for mammography and cervical screening; inequity was lower for flu immunisation and cholesterol screening but still favoured the higher socioeconomic groups. In the general practice setting, inequity in prevention was higher than inequity in health care; in the specialty setting, inequity in prevention was not statistically different from inequity in health care, although it was higher than in the general practice setting. CONCLUSIONS: If inequity in preventive medicine is to be lowered, the role of the GP must be fostered and access to specialty medicine increased, especially for cancer screening.     

Medical schools in crisis.

The medical schools of the United States are in crisis because of poor teaching methods, misdirected training of medical students, and failure to respond to the needs of the population. Much of the increased cost of medical care can be blamed on high technology and the type of training provided in the medical school. Students are trained in hospital care and use of technology to forward treatment rather than in the ambulatory and family practice care they will use later in their careers. Medical schools are to be blamed for teaching specialty medicine and thus providing large numbers of unneeded surgeons and other specialists. In addition, too many physicians of all sorts are being trained; this raises the cost of medical care to the population as a whole. Proposals are made to limit the number and kind of specialties, to restrict medical school enrollments, to train medical students in ambulatory environments, and to reorient medical care from the hospital to less costly environments. With the DRG regulations and pressure from government, medical schools must alter their curriculum in order to meet the challenges of the future.     

Experiences with a combined residency in internal and preventive medicine

BACKGROUND: The importance of integrating preventive medicine training into other residency programs was reinforced recently by the residency review committee for preventive medicine. Griffin Hospital in Derby CT has offered a 4-year integrated internal medicine and preventive medicine residency program since 1997. This article reports the outcomes of that program. METHODS: Data were collected from surveys of program graduates and the American Boards of Internal and Preventive Medicine in 2005-2007, and analyzed in 2007-2008. Graduates rated the program in regard to job preparation, the ease of transition to employment, the value of skills learned, the perceived quality of board preparation, and the quality of the program overall. Graduates rated themselves on core competencies set by the Accreditation Committee for Graduate Medical Education. RESULTS: Since 1997, the program has enrolled 22 residents. Residents and graduates contribute significantly toward quality of care at the hospital. Graduates take and pass at high rates the boards for both for internal and preventive medicine: 100% took internal medicine boards, 90% of them passed; 63% took preventive medicine boards, 100% of them passed). The program has recruited residents mainly through the match. Graduates rated most elements of the program highly. They felt well-prepared for their postgraduation jobs; most respondents reported routinely using preventive medicine skills learned during residency. Graduates either have gone into academic medicine (31%); public health (14%); clinical fellowships (18%); or primary care (9%); or they combine elements of clinical medicine and public health (28%). CONCLUSIONS: Integrating preventive medicine training into clinical residency programs may be an efficient, viable, and cost-effective way of creating more medical specialists with population-medicine skills.     

Problems in the current education and training system for occupational health physicians in Japan and strategies to solve them

Occupational Health Physician (OHP) has been defined as a title in the Occupational Safety and Health Law since 1972 when the Law was first implemented. The Law stipulates that each manager of an establishment with 50 or more workers is requested to appoint an OHP from among qualified physicians. The small number of applicants to OHP, especially from the younger generation, has continued for more than twenty years causing the average age of OHPs in Japan to rise. The shortage of successors to OHPs in active service is also very serious. A rapid increase in the number of graduates from medical schools is expected in the near future and as a result many untrained physicians in occupational health will flow into this field. It is necessary to establish an educational and training system which is related to an OHP certification system, so that the ability of OHP can be improved and that they will be able to expand their specialty. To reach this final goal, analyses and planning on the following issues of OHP must be done comprehensively; responsibilities, specialty, educational methods and course, necessary number to be trained and its allocation, and cooperation with other specialists in the field. It is also crucial to establish an effective relationship between the occupational health service system and the community health service system. Some suggestions are made to promote these issues.     

The rise and fall of occupational medicine in the United States

Thirty years ago, occupational medicine was one of the smallest of all the medical specialties, ignored by most physicians and medical schools. Occupational physicians were more likely to have entered the field through career transition than by residency training. In 1970, governmental agencies sought to transform occupational medicine into a major clinical specialty. Influential groups projected a need for large numbers of physicians in the field. Residency training was expanded, as were other teaching programs. However, industry and its workers' compensation insurance partners were not widely included in these plans. For that reason, among others, many physicians entering the field met with disappointment. About half the corporate positions for occupational physicians have disappeared in the last decade. Private practice opportunities turned out to be much more limited than planners had anticipated. Attempts to bring occupational medicine into the curriculum of the medical schools failed. Many of the residency programs that had been created are now closing. The proposal that occupational medicine create a joint specialty with environmental medicine is not widely accepted by the rest of medicine. Because so few physicians obtain board certification, it appears that the specialty of occupational medicine is returning to its former obscurity.     

Influence of residency training on occupational medicine practice patterns

OBJECTIVES: A relatively high proportion of occupational medicine (OM) specialists have not had formal residency training in OM. Members of the Western Occupational and Environmental Medicine Association, a professional organization of OM specialists, completed a postal questionnaire (160 of 561 members). METHODS: Educational background, practice setting, practice activities, and skills considered relevant were compared between those with and without formal training. RESULTS: Both groups had considerable focus in clinical care, musculoskeletal medicine, and workers' compensation. However, those with formal training practice in a broader variety of settings were less likely to have practiced another specialty, and used additional skills (toxicology, industrial hygiene, and epidemiology) in their practices. Formal education appears to create a greater diversity of skills and opportunities, but it does not appear to create a group of physicians disinterested in "front-line" occupational medicine practice. CONCLUSIONS: The data support the need for formal residency programs but also highlight the importance of access to formal training for midcareer physicians.     

健康中国战略下临床医学培养方案之预防医学课程体系现况研究

目的 了解健康中国背景下我国各高校临床医学培养方案中预防医学课程设置现况。方法 抽取全国各区域共36份临床医学专业培养方案进行统计分析。内容包括基本信息、培养目标涉及预防理念的情况、预防医学课程开设情况等。结果 所有培养方案中,22份（61%）在培养目标中未提及预防或群体健康;只有1所高校将预防医学与基础医学、临床医学一起列为主干学科。预防医学核心课程（卫生学、医学统计学、流行病学、临床流行病学、循证医学和社会医学）的总学时数从80～252不等,平均为（156.7±43.2）学时。预防医学课程占总课时数的百分比平均为4.3%±1.1%,最低的仅占2.5%,最高的也只占7.5%,均不足总课时数的10%。各高校之间预防医学各门课程的学时数差异较大。结论 现有临床医学专业人才培养方案中预防理念渗透不足,预防医学课程学时数占比极低,各高校预防医学课时数差异较大。加强新时代临床医学生预防理念的培养迫在眉睫,建议从强化预防为主的观念、完善临床医学课程体系、强化预防与临床融合发展和注重临床研究能力提升4个方面不断完善临床医学专业人才培养方案。     

Family Medicine Spokane Rural Training Track: 24 years of rural-based graduate medical education

Twenty percent of the US population lives in rural communities, but only about 9% of the nation's physicians practice in those communities. There is little doubt that the more highly specialized physicians are, the less likely they are to practice or settle in rural areas. There is clearly a population threshold below which it is not feasible for specialist (in contrast to generalist) physicians to pursue the specialty in which they have trained. Much of rural America falls below that threshold. This leaves large geographic areas of America to the primary care physician. The proportional supply of family physicians to specialists increases as urbanization decreases. Family physicians are the largest single source of physicians in rural areas. Family medicine residency programs based in rural locations provide a critical mechanism for addressing rural primary care needs. Graduates from rural residency programs are three times more likely to practice in rural areas than urban residency program graduates. There are two primary goals of training residents in rural areas: producing more physicians who will practice in rural areas and producing physicians who are better prepared for the personal and professional demands of rural practice. Rural Training Tracks, where the first year of residency is completed in an urban setting and the second and third years at a rural site (1-2 model), initially proposed by Family Medicine Spokane in 1985, have been highly successful in placing and maintaining more than 70% of their graduates in rural communities. Similar and modifications of the "Spokane RTT model" have been established around the country. Now, more than 24 years of educational experience has been accumulated and can be applied to further development of these successful family medicine residency programs.     

Training of aerospace medicine physicians

In the U. S. there are 23 recognized medical specialty boards. One of these is preventive medicine. Within preventive medicine there are three areas: Aerospace Medicine, Occupational Medicine, and Public Health/General Preventive Medicine. The preventive medicine specialties have a common core of required training including biostatistics, epidemiology, health services administration and environmental health. These, plus associated topics are covered during year one of training. Year two of training involves clinical rotations specifically tailored to the eye, ear, heart, lungs and brain, plus flight training to the private pilot level, and a Masters Degree research project for the required thesis. During year three the physicians in aerospace medicine practice full-time aerospace medicine in a NASA or other government laboratory or a private facility. To date, more than 40 physicians have received aerospace medicine training through the Wright State University School of Medicine program. Among these are physicians from Japan, Australia, Taiwan, Canada and Mexico. In addition to the civilian program at Wright State University, there are programs conducted by the U. S. Air Force and Navy. The Wright State program has been privileged to have officers from the U. S. Army, Navy and Air Force. A substantial supporter of the Wright State program is the National Aeronautics and Space Administration and a strong space component is contained in the program.