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.     

In-country and community-based postgraduate family practice training for Micronesian physicians--the Palau AHEC: a collaborative effort

The U.S. Institute of Medicine in its 1998 review of the health care systems among the U.S.-Associated Pacific Islands (USAPI) identified promotion of primary health care (PHC) and training of the regional health workforce including postgraduate training for physicians as priorities. With the support of the health leadership of the USAPI and the Republic of Palau, the John A. Burns School of Medicine (JABSOM) of the University of Hawaii captured U.S. federal Area Health Education Center (AHEC) funds to implement a postgraduate program to train Family Practitioners - physician specialists in primary care for the region. The Palau AHEC has evolved into ajoint activity of JABSOM, the University of Auckland Faculty of Medicine and Health Sciences (UAFMHS), the School of Public Health & Primary Care--Fiji School of Medicine, and Palau Community College to provide Diploma-level training in Family Practice and Community Health for Micronesian physicians.     

Teaching and training in aviation medicine in the United Kingdom

In the United Kingdom, training in aerospace medicine is provided by a range of post-graduate courses at the Royal Air Force Institute of Aviation Medicine. An Introductory Medical Officers' (IMO) course lasts for two weeks and is attended by all RAF doctors within the first few months of their entry to the Service. Its objective is to teach the elements of aviation physiology and medicine that they will need in the care of aircrew at a flying station. Four courses are held each year. A General Aviation Medicine (GAM) course is available to civilian doctors who wish to gain recognition as Authorized Medical Examiners of commercial aircrew, or who merely have an interest in the subject. It runs concurrently with the IMO course, and much of the material is common to both. Greater emphasis is, however, given to clinical teaching and to civil aviation. The GAM course also occupies two weeks of teaching. A course leading to the Diploma in Aviation Medicine is held once each year, and lasts for six months. It is open to all who have at least one year of previous experience, and has been attended by 244 military and civilian doctors from 25 countries. The D Av Med course covers every aspect of aerospace medicine at an advanced level, and its standard is at least as high as that of a M Sc degree. The Diploma is a recognised academic qualification awarded by the Royal College of Physicians. Royal Air Force medical officers receive an extra three weeks of training immediately following the D Av Med course, to educate them in procedures and policies specific to the RAF. This Advanced Course is essentially practical, and those who complete it are designated as Flight Medical Officers. They receive refresher training given at regular intervals thereafter. Aircrew are taught the basic principles of aviation medicine when they attend the RAF Aviation Medicine Training Centre for training in the use of their personal protective equipment assemblies. These courses are specific to the type of aircraft to be flown, and a pilot will undergo at least four during his flying career. Short courses of a specialised nature are also offered to clinical consultants, medical students, senior Air Force officers, nurses and others. It is now recognised in the United Kingdom that aviation medicine is a component of occupational medicine, and the Royal College of Physicians accepts the D Av Med as evidence of formal education in that branch of medicine.(ABSTRACT TRUNCATED AT 400 WORDS)     

The U.S. Air Force HEART Program: The Air Force perspective

The U.S. Air Force Health Evaluation and Risk Tabulation (HEART) Program was initiated to design and test a preventive cardiology program for active-duty Air Force members. Most cardiovascular incidents in active-duty personnel occur at a career point which significantly magnifies their operational and fiscal effect as the bulk of events disable or kill personnel during their years of peak productivity. A registered nurse managed the program at each of the four demonstration bases. The number of medical technicians and health counselors varied according to base population. The program includes risk factor screening, risk ranking, basewide education, and focal group intervention for those at high risk. Screening consisted of a health and habits questionnaire, blood pressure measurement, serum glucose, serum total and HDL cholesterol, as well as serum thiocyanate and exhaled carbon monoxide. The total population screened at first screen was 12,000 and 8,000 are expected at second screen. It is likely that due to the military capability for long-term follow-up, primary prevention begun at the time of entry to active duty could effectively reduce the number of cardiovascular events experienced yearly in the Air Force. The final product of HEART will be a detailed plan for an Air Force-wide preventive cardiology plan.     

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.     

The University of Maryland experience in integrating preventive medicine into the clinical medicine curriculum.

Lifestyle risk factors play a major role in the etiology of premature mortality, morbidity, and disability in the United States. Numerous professional groups as well as the Surgeon General of the Public Health Service have recommended that increased attention be devoted to training medical students and physicians to improve their knowledge and skills in health promotion and disease prevention. Such training is critical for attaining many of the "Healthy People 2000" objectives. For a variety of reasons, however, most medical schools have had difficulty in successfully integrating preventive medicine into their clinical curriculums. This article describes the critical elements that allowed the faculty at the University of Maryland School of Medicine to accomplish this goal through its fourth year clinical preventive medicine course. The strategies employed in this course may serve as a model for other institutions to achieve the integration of preventive medicine into their clinical curriculums.     

Screening for cervical and breast cancer among Caribbean immigrants

A screening program for cervical and breast cancer, focused on immigrant Caribbean women, was carried out at neighborhood sites (churches, schools, etc.) in a low-income area of Brooklyn, New York.The yield of abnormal Pap tests was 13.3/1000 women screened; the yield of breast cancer was 2.2/1000 women examined. Approximately half of the Haitian immigrants (N=361) had no prior Pap test, compared to one-quarter of the English-speaking Caribbean immigrants (N=228) and one-tenth of the U.S.-born Black women (N=264). Only 47% of Haitian women had a regular source of health care compared to 74% of the English speaking Caribbean women and 83% of the U.S.-born Black women. Haitian women were much less likely to practice breast self-examination or to use contraception than were U.S.-born Black women.This program reveals significant needs for preventive health services among low-income Caribbean immigrant women, and demonstrates that selective neighborhood-site programs can be effective in reaching those in need.Rachel G. Fruchter, MPH, PhD, is Assistant Professor, Department of Obstetrics and Gynecology. Carolyn Wright, MS, is Community Health Educator/Coordinator, Department of Preventive Medicine and Community Health. Barbara Habenstreit, MA, is Assistant to the Chairman, Department of Preventive Medicine and Community Health. Jean Claude Remy, MD, is Assistant Professor, Department of Obstetrics and Gynecology. John G. Boyce, MD, is Professor, Department of Obstetrics and Gynecology. Pascal James Imperato, MD, MPH & TM is Professor and Chairman, Department of Preventive Medicine and Community Health, State University of New York, Downstate Medical Center.This research was supported by grants from the New York Community Trust and the Morgan Guaranty Trust Company of New York Charitable Trust     

Defining Competencies and Performance Indicators for Physicians in Medical Management

The recent and profound changes in the American health care delivery system have created a need for physicians who are trained and willing to assume a high level of responsibility for managing evolving health care organizations. Yet most physicians receive no formal training in medical administration and management because changes in medical school and residency education have lagged behind changes in clinical practice and reimbursement. To avoid haphazard approaches and unnecessary duplication of resources, it is important for physicians involved in managerial medicine to collectively identify competencies in this area needed in the marketplace. The American College of Preventive Medicine (ACPM), with funding from the Health Resources and Services Administration (HRSA), undertook an effort to identify competencies essential for physicians who will fill leadership roles in medical management. Like ACPM’s earlier effort to develop core competencies in preventive medicine, this project drew upon the theoretical model of competency-based education. This article describes the strategy we followed in reaching consensus among a diverse group of physician executives and preventive medicine residency program directors, and includes the list of medical management competencies and performance indicators developed. Recurrent issues that can sidetrack competency development projects are also presented as well as suggestions for overcoming them. The competencies can serve as a framework for expanding current core preventive medicine training in management and administration and for developing new training programs to equip physicians with the special expertise they will need to provide management leadership within the changing landscape of health care delivery.     

Preventive practicum training in healthcare organizations. The Meharry model.

BACKGROUND: Practicum training for preventive medicine residents often occurs in agencies whose community is geographically defined and whose governance is closely linked to public election. We were unsure about the financial ability of such departments to support training and are concerned that over-reliance on traditional health departments might not be best for either medically indigent populations or preventive medicine. We, therefore, sought to apply a public health model--based on a strategic partnership between nursing and preventive medicine--to a large health care organization. The result was formation of a mini-health department, suitable for fully accredited preventive medicine practicum training, within the Alvin C. York Veterans Affairs Medical Center, Murfreesboro, TN. This Center serves a defined population of 21,594 patients and about 1600 employees. The theoretical framework for the new department was based on demonstration of a close fit between the competencies expected of preventive medicine physicians by the American College of Preventive Medicine (ACPM) and activities required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Because of JCAHO requirements, many healthcare organizations already pay for preventive medicine services. CONCLUSIONS: By placing preventive medicine training faculty into existing budget slots at our institution, systemwide personnel costs for prevention decreased by about $36,000 per year, even as personnel funding for preventive medicine physicians increased from about $24,000 to $376,000 per year. Moreover, there was dramatic, sustained improvement in 17 indicators of preventive care quality as determined by an external peer review organization. In addition to providing a new venue for training, this model may also improve the quality and reach of preventive services, decreased fixed costs for service delivery, and yield new employment opportunities for preventive medicine physicians.     

Primary care,private physicians,and public health personnel: A conflict in expectations

The elimination of categorical grants and their replacement by block grants provides public health departments the opportunity to integrate their services and provide general primary care to the underserved. While some may consider this an opportunity long overdue such a change may generate considerable conflict with private physicians.Questionnaire data from private physicians and health department personnel collected in North Carolina during an experimental program of primary care delivery by health department shows that there is substantial conflict. Private physicians oppose health department involvement in general primary care and in acute ambulatory care for the medically underserved. Physicians expect health departments to focus on preventive services, especially environmental monitoring and communicable disease control. Health department personnel want to expand their efforts beyond these more traditional areas into primary care and are in apparent conflict with private physicians. The community attitudes of a group of physicians within a community as well as the attitudes of a group of public health workers were found to be a major determinant of each individual's attitude toward public health, followed by the individual's age, sex, and years of working in the community.Dr. Kirkman-Liff is Assistant Professor, Center for Health Services Administration, College of Business Administration, Arizona State University, Tempe, AZ 85287. Dr. Kaluzny is Professor, Department of Health Administration, School of Public Health 201 H, University of North Carolina, Chapel Hill, NC 27514.     

Preventive medicine residents: a national survey.

Little is known about those physicians who pursue graduate medical education in preventive medicine, including aerospace medicine, general preventive medicine and public health, and occupational medicine. We surveyed resident physicians about their academic background, financial environment, clinical activities, and professional goals. A total of 147 residents (30%) responded from a population of 498 residents. The data suggest a lack of available information about preventive medicine training and careers among medical students who subsequently pursue such training. Their economic environment is extremely diverse, with a wide range of salary, "moonlighting" hours, educational loans, and service obligations. Although the median annual salary ($24,700) is similar to the national average resident salary, 32% of respondents earned less than $20,000, and 95% have educational debts averaging $30,900. Sixty-two percent of respondents perform clinical work in their residency, whereas 76% desire future clinical work as part of their practice. This gap is most pronounced in general preventive medicine and public health. The residents express a wide range of interests in future practice of preventive medicine; 54% are interested in government work, and 33% desire academic careers.     

Rubella screening and vaccination program for US Air Force trainees: an analysis of findings.

A preventive medicine program of rubella control for trainees at the Air Force Military Training Center, Lackland AFB, Texas, was begun in October 1977. Incoming trainees were screened for rubella susceptibility, and female trainees were additionally screened for pregnancy. During the period October 1977 to December 1978, an overall rubella susceptibility rate of 17.3 per cent was determined for 71,387 trainees entering basic training. Flights (50 persons each) to which these trainees are assigned varied widely in susceptibility from 0.0-47.7 per cent. Comparisons of susceptibility rates for trainees for for geographic areas and states indicated the highest overall percentage of susceptibles were from the Pacific geographic area with California showing the highest susceptibility (24.5 per cent). Race specific susceptibility rates were found to differ significantly between Whites and Blacks, 17.6 vs 14.8 per cent, respectively. The immunization program was effective as judged by a dampening of the incidence of clinical rubella at the basic training center and at other secondary training centers.     

Family Medicine Education and Rural Health: A Response to Present and Future Needs

The importance of family medicine in providing rural health services has been established for quite some time. The need to train physicians who select the specialty of family medicine is critical at a time when medical student interest in the primary care specialties appears to be diminishing. Renewed efforts by educational institutions and incentives at the state and federal levels will be necessary to assist in the alleviation of shortages of rural physicians. The educational program at the University of Minnesota, Duluth, School of Medicine has achieved a great deal of success in training rural family physicians. A coordinated program effort, featuring the efforts of more than 200 family physicians during the past 15 years, has led to 52.5 percent of all graduates selecting family practice and more than 41 percent choosing practice sites with a population fewer than 20,000. Elements of the program at Duluth could serve as a model for other schools desiring to increase the number of students entering family medicine and rural practice.     

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.     

John P. Craig,MD, MPH. Physician-Scientist,Educator, and Mentor. 1923–2016

John P. Craig (1923–2016) was an eminent physician-scientist, gifted educator, and greatly valued mentor. Born in West Liberty, Ohio on 29 November 1923, he attended Oberlin College, and received his medical degree from Case Western Reserve University, School of Medicine. This was followed by an internship at Yale University Medical Center, and then service in the U.S. Army during the Korean War. He was a battalion surgeon, preventive medicine officer, and epidemiologist. While in Korea, he conducted important investigations of hemorrhagic fever among American troops. His observations led to the recognition of hemorrhagic fever with renal syndrome, now called Korean hemorrhagic fever. He also identified a new Hanta virus. Craig received his Master of Public Health degree magna cum laude from the Harvard School of Public Health. He then worked with Nobel Laureate, Max Theiler, at the Rockefeller Foundation. Soon afterwards, he joined the faculty of the Department of Microbiology and Immunology at the State University of New York, Downstate Medical Center, where he established a new research laboratory. Over the years, his research focused on diphtheria infections and cholera. He became internationally respected for his work on cholera, and specifically on cholera toxin and its relationship to vascular permeability. He served for over 6 years as the Chair of the Cholera Panel of the U.S.-Japan Cooperative Program, and in this position set the direction for future research. The author of over 100 articles published in the peer-reviewed scientific literature, he also gave numerous presentations at national and international scientific meetings on a wide range of microbial diseases. Craig was highly regarded by colleagues and students as a superb teacher. He was a leader in initiating patient-oriented problem-solving (POPS) exercises for medical students. He also led curricular reform in the medical school in the 1990s whose purpose was to reduce lecture hours and expand time for small-group interactive sessions. Craig was designated Distinguished Teaching Professor by the State University of New York, and inducted as an Honorary Alumnus of the College of Medicine. The John P. Craig Award for Excellence in Microbiology and Immunology was established in 1993, and is annually presented to a graduating medical student. Following retirement to Tucson, Arizona, Craig devoted time to planning and teaching a tropical medicine course in Costa Rica that was co-sponsored by the University of Costa Rica Medical School and Louisiana State University. He was a member of the Board of Managers of the Wright Nature Center in Trinidad, and an active volunteer in the Herpetology Department of the Arizona-Sonora Desert Museum in Tucson, Arizona. He also had a great interest in ornithology. John P. Craig passed away in Tucson, Arizona on 27 September 2016 in his ninety-third year. He was an eminent success as a research scientist as well as an outstanding educator and mentor. As a result, he had a lasting influence on the lives and careers of both students and colleagues.     

Residency Training in Preventive Medicine

In responding to questionnaires, directors of 37 of the 49 approved residency programs in preventive medicine (excluding aerospace medicine) reported that 285 physicians had entered such training in the academic years, 1960 to 1968. Of these, 92% proceeded into the second year, but only 45% continued into the third. Gainful employment, military service, and residency programs in other specialties were major avenues of loss. The chief difficulty in recruitment appeared to be lack of teaching and indoctrination in preventive medicine during medical school. The greatest monetary difficulties were related to instability of governmental funding and the fact that residents in preventive medicine usually do not fulfill a “service function” in academic settings. A significant number of full-time faculty positions in departments of preventive medicine are vacant. Respondents provided a number of suggestions for improvement.     

Inaugural address of the 162nd president of the American Medical Association

On June 26, 2007, Ronald M. Davis, MD, was inaugurated as the 162nd president of the American Medical Association at an ornate ceremony in the Grand Ballroom of the Hilton Chicago Hotel. He is the first AMA president to be board-certified in preventive medicine. After Dr. Davis completed the Epidemic Intelligence Service program and the preventive medicine residency program at the U.S. Centers for Disease Control and Prevention, he served as director of CDC's Office on Smoking and Health and then as medical director of the Michigan Department of Public Health. Since 1995, he has served as director of the Center for Health Promotion and Disease Prevention at the Henry Ford Health System in Detroit. By tradition, the presidents of state medical societies and the leaders of a few other medical organizations sit on the dais during the AMA president's inaugural speech. Reflecting Dr. Davis's interest in strengthening the partnership between clinical medicine and public health, he invited leaders of seven preventive medicine and public health organizations to join him on the dais during his address: the Aerospace Medical Association, the American Association of Public Health Physicians, the American College of Occupational and Environmental Medicine, the American College of Preventive Medicine, the American Public Health Association, the Association of State and Territorial Health Officials, and the National Association of County and City Health Officials. Dr. Davis's inaugural address appears below, except for a portion at the beginning in which he gave tribute to many family members, friends, and colleagues for their support through the years. This portion of his speech can be found on the Journal's website at www.ajpm-online.net.     

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.