Wanted: better public health training for family physicians

Marie-Renée B-Lajoie; Lucas Chartier

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But what do you mean by "public health training?"
Lawrence C. Loh, MD, MPH, CCFP, FRCPC, FACPM

Published on: 27 June 2016
Some cold water on the realities of modern public health
Franklin H Warsh

Published on: 15 June 2016
Public Health training for family physiicians
John K. Carsley

Published on: 15 June 2016

Published on: (27 June 2016)
Page navigation anchor for But what do you mean by "public health training?"
But what do you mean by "public health training?"
Lawrence C. Loh, MD, MPH, CCFP, FRCPC, FACPM, Associate Medical Officer of Health
As a public health physician serving as an Associate Medical Officer of Health, I was initially excited at seeing the title of this article from B-Lajoie and Chartier, but as I read on, I had mounting concerns around the content. The first concern was a lack of clarity around what additional public health training was being suggested for family physicians. (1) This was compounded by a lack of understanding as to the wor...
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As a public health physician serving as an Associate Medical Officer of Health, I was initially excited at seeing the title of this article from B-Lajoie and Chartier, but as I read on, I had mounting concerns around the content. The first concern was a lack of clarity around what additional public health training was being suggested for family physicians. (1) This was compounded by a lack of understanding as to the work of public health physicians, and the misuse of a very broad definition of the term "public health" that seemed to be "work by a physician involving data, advocacy or administration... irrespective of where it is conducted."
The first concern was exemplified in the statement presented by the authors that "family medicine programs [already] attempts to put some emphasis on public health training." This statement fails to recognize the importance of terminology. While one can agree that family medicine training programs are increasingly and appropriately emphasizing public health concepts in patient care, such as advocacy, health equity, and the social determinants of health, suggesting that this is equivalent to "public health training" totally discounts the specialised training of public health physicians.
The authors' thought process is not unique, though; in recent times, the term "public health work" has been increasingly used as a catch-all to anything that is "not clinical", such as "working with data", administration, advocacy efforts, or pet research projects. (2) This creates confusion between the actual public health practice of public health and preventive medicine specialists, and the work of other physicians, notably family doctors, who believe that public health practice is the mere application of public health concepts to issues (e.g. advocacy around homelessness or preventive services research.)
Public health practice, as carried out by specialist Medical Officers of Health (MOHs), involves balancing conflicting agendas, evidence, and resources towards determining optimal population health programming and policy. This work is typically and necessarily apart from the health care system, because health is typically what occurs beyond the walls of hospitals and consultation rooms. The suggestion by the authors that family doctors "primarily" had a role in driving the twelve public health advancements of the past century thus further demonstrates a fundamental misunderstanding of the prevention continuum and the work done by public health agencies. (3)
For example, concerning motor vehicle safety, what role did clinicians play in pushing seatbelt legislation, stricter drink driving legislation, graduated licencing, or improvements to road design? (4) Similarly, around tobacco control, besides providing counselling and tertiary cessation care, what role did family doctors play in creating smoke free spaces, plain-package labelling, or tobacco taxes? (5) History records these achievements as being from the work of public health physicians working in concert with multidisciplinary teams in public health agencies at all levels of government, in partnership with non- healthcare stakeholders (politicians, school boards, civil society, private sector, etc.). This work created the necessary societal contexts that resulted in improved community health.
The authors also contend that "public health needs to better engage doctors" in becoming advocates. The fundamental question that underpins this is: in promoting the health of the community, to what extent should public health focus on engaging primary care, versus other sectors? (6) Indeed, public health already has robust interactions with primary care around screening and vaccination, and family doctors would do well to better understand these linkages.
However, for other issues of community health concern, the public health partner largely depends on what work needs to be done. If anything, save for surveillance and preventive services, public health agencies and family physicians often have opposing goals. The work of public health is to keep people healthy and out of the healthcare system, while family doctors represent the first point of entry for patients for whom their health needs to be restored. (7)
In this vein, the authors also consistently confuse healthcare leadership and administration with public health practice. References to the complexity of the healthcare environment, allocation of healthcare resources, and the effectiveness of healthcare organizations show a fundamental misunderstanding of the work public health that is largely done apart from, rather than within, the healthcare system.
The authors also continually state that public health physicians do not practice clinically as though this is a bad thing. This leads to two additional points: firstly, just because public health doctors do not practice clinically does not mean they do not have clinical knowledge. The Royal College expectations and responsibility of many public health physicians is to bridge their knowledge of biomedical sciences and diseases with a public health skill set in promoting and protecting health at a population level. (8) Secondly, evidence around what makes Canadians sick means that then the work of public health physicians is necessarily non-clinical, and often requires attention to sectors outside of healthcare. (9)
One can readily agree with the authors that public health physicians and family physicians are necessary partners on certain issues of population health importance. However, their roles and the extent of the relationship need to be clear; we must recognize that each specialty serves a different purpose. (10) Certainly, there are linkages that exist between the public health and the family medicine community that warrant careful attention (e.g. around vaccinations, screening, reportable diseases, and using population data in diagnosis). However, suggesting that family doctors should lead on broader population health issues ignores highly specialised training that public health specialists receive. (11)
To that end, I want to believe that the authors originally intended to call for better exposure to public health concepts in family medicine training, with the goal of improving the existing partnerships between public health and family medicine. Indeed, while I am grateful for the authors' interest in public health, I can't help but feel that a better understanding of the real work of public health would have helped to clarify many of the concepts as presented in the original article.
References
1. B-Lajoie MR, Chartier L. Wanted: better public health training for family physicians. Can Fam Physician. 2016 Jun;62(6):471-3.
2. Loh, LC. Public Health and Why Terminology Matters. BMJ [blog]. 2016. Available at: http://blogs.bmj.com/bmj/2016/05/26/lawrence-loh- public-health-and-why-terminology-matters/ (Accessed June 24, 2016)
3. Canadian Public Health Association. 12 great achievements. Ottawa, ON: Canadian Public Health Association; 2015. Available from: http://cpha.ca/en/programs/history/achievements.aspx (Accessed June 24, 2016.)
4. Canadian Public Health Association. Reducing Deaths and injuries on our roads. Ottawa, ON: Canadian Public Health Association; 2015. Available from: http://www.cpha.ca/en/programs/history/achievements/07- mvs/roads.aspx (Accessed June 24, 2016)
5. Warner KE Tobacco control policies and their impacts. Past, present, and future. Ann Am Thorac Soc. 2014 Feb;11(2):227-30. doi: 10.1513/AnnalsATS.201307-244PS.
6. Moloughney BW. Public health medicine, public health practice, and public health systems. Can J Public Health. 2013 Mar 4;104(2):e115-6.
7. Loh LC. Please stop calling it a "health system." Can J Public Health. 2016 (in press)
8. Royal College of Physicians and Surgeons of Canada. Objectives of Training in Public Health and Preventive Medicine. 2014. Available at: http://www.royalcollege.ca/cs/groups/public/documents/document/y2vk/mdaw/~edisp/tztest3rcpsced000887.pdf (Accessed June 24, 2016).
9. Canadian Medical Association. Health equity and the social determinants of health. [website] Available at: https://www.cma.ca/En/Pages/health-equity.aspx (Accessed June 24, 2016).
10. Corber S. Medical officers of health, public health and preventive medicine specialists, and primary care physicians: how do they fit? Can J Public Health. 2013 Apr 2;104(2):e111-2.
11. Loh LC, Harvey BJ. A look to the past as we look ahead: the specialty of public health medicine in Canada. Can J Public Health. 2013 Jan 8;104(2):e108-10. Review.
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (15 June 2016)
Page navigation anchor for Some cold water on the realities of modern public health
Some cold water on the realities of modern public health
Franklin H Warsh, MD MPH CCFP
As someone who went through the additional training (an MPH through part-time studies) suggested by Drs. B-Lajoie and Chartier, and even worked for a number of years part-time at an Ontario Public Health Unit, I agree that public health is something of a forgotten stepchild in medicine. However, before initiating an expansion of public health training for physicians, we need to think carefully about what it is we're hopin...
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As someone who went through the additional training (an MPH through part-time studies) suggested by Drs. B-Lajoie and Chartier, and even worked for a number of years part-time at an Ontario Public Health Unit, I agree that public health is something of a forgotten stepchild in medicine. However, before initiating an expansion of public health training for physicians, we need to think carefully about what it is we're hoping to achieve.
With regards to the education component, I enjoyed my MPH program, but would be lying if I thought that most of the curriculum applied to medical work. In fact, a good chunk of the material went well beyond the scope of activities performed in public health work, and bordered on promoting a particular political leaning. *Many* doctors I know are strongly devoted to their patients and their art, but have little patience for being told what to think about tax policy and politics.
The typical job of a public health doctor is also something of an elephant in the room. Yes, there's good work to be done on health promotion, and medical insight is essential in managing an outbreak. But major parts of the job - tedious Ministry teleconferences, hostile (often personality-driven) media, navigating the political agendas of governing Boards, organizational administration, squabbling over budgets - could hardly be construed as medicine. If not work at a public health unit, what exactly is the goal in training more doctors in public health?
Finally, and this situation might be unique to Ontario, we also have to bear in mind that a pivot to work in public health constitutes a change in scope of practice. That triggers the College of Physicians to begin its intensive meddling into one's career. My own experience tells the tale, as the CPSO continually moved the goalposts on me, demanding ever-more red tape and supervision, despite my ever-greater experience on the job. Had I known the College would see fit to do as it did, I wouldn't have bothered at all.
I suppose we can all champion having more public health content in medical school. But how do you convince a brand-spanking new class of science-minded med students that if they really want to save lives, they need to take action on poverty and homelessness? As memory serves, the material and themes were there, and even stressed in med school...it was just promptly forgotten once we all started rotating on the wards.
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (15 June 2016)
Page navigation anchor for Public Health training for family physiicians
Public Health training for family physiicians
John K. Carsley, Medical Health Officer
A million years ago (1993), Terry Tannenbaum and I published an article in CFP entitled 'How to befriend your health department'. Since then, some good and more than a few bad things have happened to public health training. While at least one university has a mandatory clerkship in public health, here at UBC, public health has virtually disappeared from the undergraduate medical curriculum. Other universities are somewhere in b...
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A million years ago (1993), Terry Tannenbaum and I published an article in CFP entitled 'How to befriend your health department'. Since then, some good and more than a few bad things have happened to public health training. While at least one university has a mandatory clerkship in public health, here at UBC, public health has virtually disappeared from the undergraduate medical curriculum. Other universities are somewhere in between. In 2015, all (except UBC) made reasoned responses to the "Future of Medical Education in Canada" project's request for improved public health and prevention teaching. More than ever, we need physicians who understand social determinants and know how to help their patients deal with them. We need physicians who use population health skills to identify problems needing advocacy. The clinician always has a credible voice at the school board, the city council, or with media. I wholeheartedly endorse Dr. Lajoie's diagnosis; the treatment is trickier. FM Department's must mobilize their allies in Public Health Schools and Departments for urgent joint action here. Time's a wasting.
Conflict of Interest:
None declared
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Competing Interests: None declared.