Cover Story
Going Public
More and more physicians are pursuing schooling in public health.
By Jeanne Mettner
Five years into his medical practice, David Hilden, M.D., was experiencing a profound shift in his thinking. An internal medicine physician at Hennepin County Medical Center (HCMC), Hilden treated people who were poor, uninsured, and uneducated, many of whom suffered from chronic conditions such as heart disease or diabetes. He was becoming increasingly aware that his patients’ health problems were caused or exacerbated by problems that medicine alone couldn’t solve. For instance, a patient might miss an appointment because she didn’t have transportation to the clinic; another might not fill a prescription because he couldn’t afford even a small copay. “What I found myself doing was playing catch-up,” says Hilden, who would sometimes reach into his own pocket and hand a patient money for medication. “I would be giving all these medications for diabetes almost when it was too late, when their diabetes was out of control.” He began to realize that he could do more than see patients individually in the office; he could also work to change public policy so people could get the care and medication they needed before they got so sick. In order to do that effectively, Hilden felt he needed a broader understanding of public health, and in 2005 he decided to enroll in the University of Minnesota’s Executive Program in Public Health Practice. He expects to receive his master of public health (M.P.H.) degree this year.
Hilden’s desire to combine macro/systems-level work with what he does at the micro/patient level is not unique. According to the American Association of Public Health Physicians (AAPHP), an advocacy organization for physicians who are involved in public health, about 10,000 physicians in the United States have earned an M.P.H. degree. Of the 30,000 members of the American Public Health Association, the world’s largest organization of public health professionals, more than 3,000 have their medical degree.
It appears more and more physicians are thinking like Hilden. “The number of physicians who are getting their M.P.H. degree is definitely increasing,” says Joel Nitzkin, M.D., M.P.H., past president of the AAPHP and a public health consultant in New Orleans. “Estimates indicate that one-third to one-half of students currently enrolled in medical school are opting to get the M.P.H. degree as well.” In Minnesota, more than 100 physicians have been enrolled in the University of Minnesota’s executive M.P.H. program, which was created in 2002 in part because of requests from practicing physicians to learn more about big-picture issues. According to Jim Hart, M.D., who directs the program, the number of physicians who enter each year has steadily increased—from six on 2004 to 14 in 2007 to 20 in 2009. In addition, the number of medical students at the university who completed an M.P.H. degree along with their medical degree grew from three in 2009 to 10 this year.
The Great Divide
Although both public health and medicine share the aim of improving health, there are big differences between the two fields, according to Edward Ehlinger, M.D., M.S.P.H., director and chief health officer at the University of Minnesota’s Boynton Health Service. Whereas medicine focuses on the health of the individual, public health is population-focused; it takes into
Paths to Public Health Practice
For physicians in Minnesota, the road to greater knowledge of public health issues can begin at three junctures—during medical school, immediately after residency, or in mid-career. At the University of Minnesota, students can complete two years of medical school, and then take a year to complete their master of public health (M.P.H.) degree before wrapping up their medical training. After residency, physicians can obtain their M.P.H. at the university while completing a fellowship in a specialty such as preventive cardiology or preventive medicine.
Physicians in Mayo Clinic’s two-year preventive medicine fellowship program earn an M.P.H. at the University of Minnesota during the first year, then go on to complete rotations in environmental and occupational health, patient education, chronic disease management, community health, and health department settings. Since it began in 1978, more than 40 physicians have received an M.P.H. while in the Mayo program. “We’ve had an increase in the applicant pool in the past several years, although it’s difficult to speculate why this is so,” says Prathibha Varkey, M.B.B.S., M.P.H., who directs the fellowship program and is a consultant to the Olmsted County Public Health Department. “The one change I have noticed is increased interest from primary care physicians who have been working for several years, who want to come back for preventive medicine training because they want to learn more about how to keep people healthy from a population-based perspective.”
Increased interest from practicing physicians led the University of Minnesota’s School of Public Health to create a new M.P.H. track in 2002. Known as the Executive Program in Public Health Practice, it offers working health care professionals (primarily physicians, veterinarians, and dentists) a way to expand their knowledge of public health and apply it to their practice. Each year, the program, which is one of a handful of its kind in the United States, accepts 20 to 25 applicants. The program consists of online courses and a three-week summer Public Health Institute. Jim Hart, M.D., the program’s director, says the program is attracting physicians from here and elsewhere. “I have students literally all over the world who complete 15 credits online, then attend the Public Health Institute for a couple of summers, then return home to complete their master’s project.”—J.M.
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account the fact that health is the responsibility of society as well as the individual. Public health practice is a collaborative undertaking, requiring the cooperative efforts of people from multiple disciplines who come from diverse backgrounds; it focuses on social justice issues such as equal opportunity for the disadvantaged; and it emphasizes prevention and education rather than medical procedures. Medicine, in contrast, homes in on specific illnesses or diseases, is specialized, and emphasizes treatment rather than prevention. “In their clearest distillations, medicine and public health contrast quite dramatically,” Ehlinger says.
It’s that difference that attracted Ehlinger himself to public health nearly 30 years ago when he was working in a small eastern Montana town heavily burdened by alcoholism, tobacco use, and obesity. An internal medicine/pediatrics physician, he was seeing 40 to 60 patients a day and encountering more health problems than he could reasonably manage. “The health care demands of the community were so overwhelming,” he recalls. “I felt like I was in a boat that had a huge leak in it; I was bailing as fast as I could, but I couldn’t keep up.”
Ehlinger wanted to be able do more than bail. He wanted to prevent health problems from occurring in the first place. To do that, he decided to get a master’s degree in public health, which he earned at the University of North Carolina. Ehlinger subsequently moved to Minneapolis in 1980, serving as a director of the Minneapolis Department of Public Health before moving to the University of Minnesota, where he continues to do clinical work and conducts research on college students, maternal and child health, and health disparities between urban and rural populations. “Studying public health markedly altered the path I chose,” he says. “It made me realize that public health and medical care are not separate approaches but rather two areas that need to be merged as much as possible.”
The Appeal
The University of Minnesota’s Hart says physicians are motivated to study public health for several reasons. One is the “ever-present weariness” that can creep into medical practices today. “Doctors are trying to take care of people who are suffering every day in a system that is very cumbersome and includes the tremendous overlay of insurance issues,” he says. “So some of the doctors come in and say they want to move their career in some direction that’s not just ‘hamster care,’ as it’s been called.”
Second, he says, some physicians realize that the problems they are encountering within their clinical practice cannot be solved by medicine alone. “The typical case might be a primary care doc who sits in the office writing out prescriptions for diabetes, hypertension, and high cholesterol day after day, and finally says, ‘maybe there’s a way to get upstream on this,’” he says.
Hart points out that some want to do research as well. “In addition to wanting to bring a population-based perspective to their clinical practice, many are looking for rigorous training in clinical research methods such as biostatistics and epidemiology,” he says.
Another reason physicians pursue a public health degree is to be more knowledgeable about global health issues. Hart says that’s part of the reason he got involved with public health. “When you start looking at the disease burden in these poor countries, it’s heavily weighted toward public health issues—poverty, dirty water, lack of food,” he says. “Unfortunately, a lot of them are difficult to do anything about, but at least physicians can be thinking about it and framing the questions in public health terms.”
Hart and others caution that physicians who earn an M.P.H. degree should not expect a promotion for their efforts. Although some go on to specialize in research or work in public health departments at the federal, state, or local level, many continue to practice medicine full time. “When you get an M.P.H. added on to your M.D., it doesn’t necessarily open up more doors for you career-wise. But when I am honest with my students about that, most of them say, ‘I know, and I want to do this anyway,’” Hart says.
Hilden, too, says physicians who study public health are motivated by something other than career advancement. “If a physician is thinking of getting an M.P.H., it should not be because of any financial advantage; you’re still going to be a doctor, and no one is going to hire you specifically because you have an M.P.H.,” he says. Hilden plans to continue his full-time practice after he earns his public health degree; but he also plans to delve into work on policies that could reduce disparities in health care and eliminate barriers to care for underserved populations. “When doctors advocate for a patient in the public realm, they’re doing as much good as when they are with the patient one on one.” He explains that when talking to administrators or lawmakers about health-related concerns, physicians bring credibility and insight into how those issues affect their patients. Hilden thinks studying public health will help him be a more effective advocate. “I have a better understanding now of how the public policy process works,” he says.
Thomas Kottke, M.D., M.S.P.H., has long known that when public health and medicine work together, they can change lives. While completing his internal medicine residency in 1978, Kottke earned a master’s of science in public health at the University of North Carolina-Chapel Hill, then got involved in public health initiatives in North Karelia, Finland, which at the time, had the highest rate of heart disease in the world. They combined population-based initiatives to reduce smoking and promote a diet that was low in sodium and saturated fat with clinical approaches to treat the overwhelming number of cases of hypertension and high blood cholesterol within the community. Today, roughly 40 years after the first interventions were introduced, total mortality from cardiovascular disease in North Karelia has decreased by 50 percent. “In 40 years, we’ve increased life expectancy by 10 years; that’s an increased life expectancy of three months for every year, year after year,” explains Kottke, who is now a practicing cardiologist at HealthPartners and a public health researcher with the HealthPartners Research Foundation. “It’s phenomenal in illustrating how much you can make a difference if you really have an understanding of how to address the problem on a public-health scale.” Over the years, Kottke has applied lessons from the North Karelia project. While working at Mayo Clinic from the late 1980s to 2004, he developed and organized CardioVision 2020, a heart disease prevention program in Olmsted County. Today, he continues to use what he learned in Finland and at Mayo as he develops and implements health policy at HealthPartners.
Blend or Break-up?
Although public health isn’t part of the curriculum at most medical schools, completing some graduate work in public health is expected for those who wish to specialize in preventive medicine (see “Paths to Public Health Practice”). Currently, the American College of Graduate Medical Education (ACGME), which oversees accreditation of medical residency programs, requires that preventive medicine residents and fellows receive an M.P.H. or related master’s-level degree (eg, master of science in public health) as part of their training. In the minds of many public health educators, the M.P.H. requirement illustrates the college’s commitment to integrating public health into clinical medicine in a meaningful way. “Preventive medicine and public health are natural allies in preventive care, and understanding the field and being trained in public health augments the arsenal of tools the preventive medicine physician brings into the field,” says Charles Oberg, M.D., M.P.H., chair of the maternal and child health program at the University of Minnesota’s School of Public Health and an associate professor of pediatrics and public health.
The public health requirement for preventive medicine may soon change. In January 2010, the ACGME proposed new requirements for preventive medicine residencies, suggesting that the formal M.P.H. requirement be eliminated. The idea is regarded as radical in the minds of many who want to maintain the M.P.H. requirement. They claim that the only way a physician can get a sense of what public health encompasses—epidemiology, biostatistics, public policy, health care administration—is to go through a master’s program.
In its winter newsletter, the AAPHP issued a response to the ACGME’s move: “The concept of a preventive medicine physician is a physician who has advanced training in the use of political and administrative methods to diagnose and ‘treat’ health issues at a group or population level. The proposed changes imply [that] basic training in public health topics not included in the usual clinical training are of such little importance that watering them down to weekly didactic sessions is a reasonable substitute for M.P.H. training.” Oberg, for one, disagrees with the ACGME’s proposed change, calling it a “poor decision,” given the important role that earning a master’s in public health has played in empowering preventive medicine physicians.
Because of what the AAPHP’s Nitzkin describes as the tremendous negative reaction from the public health and preventive medicine communities the ACGME may change its mind. “My understanding is that they are going to be backing down on their proposal to eliminate the M.P.H. requirement,” says Nitzkin, who submitted a formal comment to the ACGME in early spring. “I think they realize that offering the M.P.H. is the most practical way for physicians to secure some knowledge of public health, and it should remain a requirement, even though it’s training that is also offered to nonphysicians.”
While the ACGME sorts out the requirements for preventive medicine, a significant number of physicians and medical students continue to pursue the formal study of public health. At HCMC, Hilden is beginning to find ways to blend the two disciplines. In addition to seeing patients, he has been involved in conversations with hospital and clinic leaders to find out why patients have trouble getting to the clinic: Is transportation the issue? Are they unable to afford the visit? He also has taken part in discussions about how to reduce medication costs for patients. “Helping patients one at a time is what I will continue to do when I am in the room with them,” he says. “But outside of the clinic visit, I can work to make sure the barriers to health care aren’t getting in the way of their getting good care.” MM
Jeanne Mettner is a frequent contributor to Minnesota Medicine.