Pulse
Public Servants
As consultants to their local health boards, physicians play a role in the state’s public health system.
For Mike Wilcox, M.D., serving as the medical consultant for Scott County’s Public Health Department is a hands-on job. Twice a month, the family physician who now works in emergency medicine, provides free care out of a mobile clinic provided by the Shakopee Mdewakanton Sioux community that travels between the towns of Savage, Shakopee, and Jordan. Every other week, he sees inmates at the jail in Shakopee. He makes quarterly presentations to the county’s community health board, and communicates regularly with the nurse who coordinates its public health programs. In addition, Wilcox has written standing orders and overseen vaccination clinics; weighed in when the county developed an ordinance making it unlawful for people to host events at which those younger than 21 might consume alcohol; and helped develop protocols and policies related to mental health, sexually transmitted diseases (STDs), and emergency preparedness.
The many tasks that comprise Wilcox’s part-time work for the county are now included in a job description. But the list of duties he performed when he began working with the county two decades ago wasn’t nearly as long as it is today. Wilcox was initially contracted only to serve as medical director for the county’s emergency medical services. Over the years, as he has gotten to know the jail captain, the county administrator, and the needs of the community (Scott County officials have uncovered disturbing statistics about substance abuse, STDs, and other problems), his role has evolved. “I’ve developed my take on this [public health consultant role] with years of experience in Scott County,” he says.
Like Wilcox, 52 other Minnesota physicians serve as medical consultants to their community health boards. All are charged by state law “to ensure appropriate medical advice and direction for the board of health and assist the board and its staff in the coordination of community health services with local medical care and other health services.” The law says little about what these physicians should actually do, how many hours they should work, how they should interact with their community health board, or what issues they should address.
To a large extent, that’s because the public health system in Minnesota is locally driven. The system was set up with passage of the local public health act in 1976, which calls for cities, counties, or regions to establish community health boards that do formal needs assessments and develop policies, programming, and services based on the findings. Thus, what medical consultants do reflects the priorities of the community.
“The important thing to understand is that the consultant is there to meet the needs of the local community health board,” says Debra Burns, director of the Minnesota Department of Health’s Office of Public Health Practice. The boards then decide how to use the physician’s expertise.
Many Meetings
In Carver County, which is adjacent to Scott County in the southwest metro, the tasks done by its public health medical consultant, Jonathan Larson, M.D., are quite different from those Wilcox performs. Rather than provide hands-on care and consultation, Larson’s contributions have been more along the lines of systems thinking and networking.
Some time ago, Carver County decided that rather than provide many services directly, the public health department would enlist other sectors of the community to work on improving the health of the county’s residents. Larson embraced that idea. “We chose a grass-roots approach, and Dr. Larson helped us think through how this would relate to community efforts,” says Rae Jean Madsen, R.N., P.H.N., Carver County’s community health services administrator. For example, rather than create programs for the large number of aging baby boomers, the county’s public health staff worked with representatives from business, transportation, housing, health care, and city government to draw up a master plan that involves all of those sectors. Madsen says Larson brought both a medical perspective and a view of the big picture to those discussions. “He’s able to look at the individual, the family, and community health as it relates to systems and populations. That integration is what’s invaluable,” she says.
Building relationships and raising awareness are also a big part of what Neal Holtan, M.D., M.P.H., does as the half-time medical director for the St. Paul-Ramsey County Department of Health. In fact, Holtan considers attending meetings and participating in discussions as central to public health practice. When the goal is changing the health status of entire communities, accomplishing anything requires the efforts of a network of people working toward the same goal, he explains. “No one can do any of this stuff independently.”
Not a Matter of Money
Minnesota state law requires that local public health departments must have a written agreement with, a contract with, or employ physicians as medical consultants. But it doesn’t stipulate that they should be paid for their work.
The St. Paul-Ramsey County Department of Health’s Neal Holtan, M.D., M.P.H., is one of a handful of medical consultants actually employed by a community health board. As such, he earns a salary. More commonly, the state’s medical consultants receive a stipend for their services or volunteer them. And the physicians who work as medical consultants often view the role as community service.
The number of hours they spend in their medical consultant role can vary widely. For instance, Don Deye, M.D., estimates he puts in two to three hours a month working as the medical consultant for the Isanti-Mille Lacs community health board. Scott County’s Mike Wilcox, M.D., spends an estimated quarter to a third of his time working as its medical consultant. And St. Paul-Ramsey’s Holtan works half time.
Wilcox says the pay he receives for his services is appreciated but doesn’t match the hours and effort he puts in. He also notes that he pays out of pocket for a malpractice insurance policy to cover his medical consultant work. “Those of us who do this have a kind of passion,” he says. “We really want to do this. Getting paid for it is not the biggest issue.”—C.P.
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Holtan says his boss at the health department, Rob Fulton, encourages him and other senior managers to make as many connections as possible both within and outside of the county. So with Fulton’s blessing, Holtan sits on four advisory committees for the Minnesota Department of Health, including a steering committee for the heart disease and stroke prevention plan. He’s also an advisor for HealthPartners’ occupational medicine residency program and for Mayo Clinic’s fellowship in preventive medicine. And he’s involved in organized medicine.
Holtan says the number of meetings he attends surprises the residents who do rotations with him. “Meetings for public health are like the operating room for a surgeon,” he says. “That’s where we do our work.”
Holtan also does what might be considered more tangible work, supervising the public health lab and seeing patients at the health department’s tuberculosis clinic in St. Paul. And like his many medical consultant counterparts around the state, he writes standing orders for nurses, oversees immunizations, and answers questions about infectious disease outbreaks and other concerns.
New Interest in the Position
Just what public health medical consultants should know and do, and how they could enlist greater support from the medical community has been a topic of discussion at recent meetings organized by the Minnesota Medical Association (MMA) and the Twin Cities Medical Society (TCMS).
Last October, the Minnesota Department of Health’s Burns and Holtan presented an overview of the state’s public health system and the medical consultant’s role to the MMA’s public health committee. At that meeting, Holtan suggested it would be useful to find ways to foster communication among the consultants, help them develop new skills, and support them with education.
In May, the committee, with help from the Minnesota Department of Health, arranged a conference call with a focus group of outstate medical consultants—its first attempt to discuss with them how the Department of Health and the MMA could assist them. The TCMS has held two meetings for metro-area medical consultants that have focused on finding ways the medical society might better support public health in general and the metro-area medical consultants specifically.
Among the ideas that have emerged from these meetings are to develop more training opportunities for medical students and residents, create a handbook to orient physicians to the medical consultant role, develop or find appropriate continuing medical education for the consultants, and find more ways to help the consultants connect with each other.
Exposure Needed
Wilcox, Larson, and Holtan would like to see more physicians become interested in public health policy and practice. Each says exposure to the field and the problems that require communitywide effort is the key to making that happen.
Wilcox, who has no formal training in public health, says his interest grew out of his long-time work in Scott County, where he has encountered patients without health insurance or medical homes. He decided he wanted to help ensure such folks had better access to care. Larson says a rotation during his residency at the University of Minnesota that had him following public health nurses and meeting with community organizations helped him understand what public health was about. “It just lit a spark in me for this work. I took an interest in it, and it grew over the years.” Larson is now pursuing formal coursework in public health at the University of Minnesota.
Wilcox predicts the next generation of public health medical consultants will hold degrees in public health. But he doesn’t think that there should be a single job description for the state’s medical consultants or other big changes in the way the state’s public health system operates. “Each county needs to look internally at what the needs might be in the area of public health and sort out what the responsibilities might be for a medical director ... then find an individual who’s ready to step up and do this kind of work,” he says.
Having described an approach much like the system that’s been in place since 1976, Wilcox clearly thinks Minnesota’s public health system, which has communities setting their public health priorities and then working with a medical consultant to act on them, is on the right track.—Carmen Peota